OSHA Medical Questionnaire


OSHA or Occupational Safety and Health Administration medical questionnaire are undertaken by divers and dive instructors to assess whether they have any health hazards or not. The questionnaire governs commercial divers working in the gas and oil industries. Only after undertaking thus questionnaire divers can be declared medically fit to go for underwater diving.

Sample OSHA Medical Questionnaire

Name: _____________

Age: ______________

Sex: ________________

Address: ____________________

 

  1. Do you wear a respirator?

a)   Yes

b)   No

  1. If the answer to the above question is yes, what kind of respirator do you wear?

a)   Filter mask respirator

b)   Half face piece type

c)   Full face piece type

d)   Powered  air purifying

e)   Supplied air

f)    Self contained

  1. Do you have the habit of smoking tobacco?

a)   Yes

b)   No

  1. Do you have any history of having seizures?

a)   Yes

b)   No

  1. Do you have diabetes?

a)   Yes

b)   No

  1. Are you claustrophobic?

a)   Yes

b)   No

  1. Do you have history of suffering from asthma?

a)   Yes

b)   No

  1. Have you ever suffered from chronic bronchitis?

a)   Yes

b)   No

  1. Did you ever have pneumonia?

a)   Yes

b)   No

  1. Do you a history of lung cancer?

a)   Yes

b)   No

  1. Did you ever have had any of the following injuries?

a)   Broken ribs

b)   Chest injury

c)   None

  1. Did you ever had shortness of breath while climbing a hill or walking up an inclined road?

a)   Yes

b)   No

  1. Do you feel shortness of breath while walking on level ground?

a)   Yes

b)   No

Patient Name: Howard Mayer

Dated: 24th November, 2010

Category: Medical Questionnaire

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