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Respiratory and Asbestos Questionnaire for Occupational Health

Respiratory and Asbestos Questionnaire for Occupational Health 2026

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The document is a Respiratory and Asbestos Questionnaire designed for occupational health assessments. It collects detailed medical history and current health status of employees or applicants to evaluate their ability to wear respirators safely. The questionnaire includes sections on personal information, respiratory and cardiovascular health, symptoms related to lung disease, past medical history, occupational exposure to hazardous substances, and family health history. It aims to ensure compliance with OSHA regulations regarding medical surveillance for workers exposed to asbestos and other harmful materials.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name, patient ID, date of birth, today's date, employer, job title, length of employment, age, and sex. Ensure accuracy as this information is crucial for assessment.
In the respirator section, check all applicable types of respirators you will use. If you have previously worn a respirator, indicate the type(s) used.
Proceed to answer the medical history questions regarding smoking habits and any past or current pulmonary or cardiovascular conditions. Be honest and thorough in your responses.
Continue through the form by addressing symptoms related to lung disease and any medications you are currently taking. This section is vital for understanding your health status.
Finally, review all entries for accuracy before submitting. Use our platform's features to save or share the completed questionnaire as needed.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (93 Votes)
2015	4 Satisfied (46 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the SGQR score?

Georges Respiratory Questionnaire (SGRQ) is designed to measure health impairment in patients with asthma and COPD. Four scores are calculated Symptoms, Activity, Impacts, and Total. Lower scores indicate better health. Maximum raw scores: 662.5, 1209.1, 2117.8, 3989.4, respectively.

What is the standard respiratory questionnaire?

If you permit the use of respirators other than filtering facepieces, you must pay for required medical evaluations for voluntary users and provide voluntary users with appropriate facilities and time to clean, disinfect, maintain, and store respirators.

What is a respiratory questionnaire?

Respiratory health for occupational exposures A respiratory questionnaire is a structured questionnaire or survey designed to assess an individuals respiratory health in relation to their occupational exposures.

What is the OSHA respirator questionnaire?

The St Georges Respiratory Questionnaire is a standardized self-completed questionnaire for measuring impaired health and perceived well-being (quality of life) in airways disease.

What is a good SGRQ score?

St Georges Respiratory Questionnaire A total score incorporates scores from each component of the SGRQ which ranges from 1 to 100, where 0 indicates best health and 100 indicates worst health.