Yes No Yes No Fractured bone that did not properly heal Enlarged spleen Osteomyelitis (bone infection) Low white blood cell count 6.15 Neurological Disorders Blood clots or need for blood thinners Seizures (fits) or Epilepsy Too many blood cells (polycythemia) Balance, walking or movement problems 6.18 Endocrine and Metabolic Passing out while at rest or with activity Diabetes Tremors Thyroid problems Muscular weakness Disease of the pituitary, adrenal, or parathyroid glands Paralysis of any limb Other hormone or nutrition problem Memory problems 6.19 Systemic Diseases and Miscellaneous Migraine or other chronic headaches Lupus, scleroderma, rheumatoid arthritis, or dermatomyositis Altered sensation or numbness Burn injury with ongoing problems Cerebral aneurysm Heat stress or other heat injury Multiple sclerosis 6.20 Tumors and Malignancies Muscular dystrophy Tumor, malignancy, or cancer Head injury 6.21 Psychiatric Conditions Bleeding in head or brain Depression or other mood disorders 6.16 Skin Anxiety Skin cancer Alcoholism Rashes Other substance abuse Skin grafts Other psychiatric condition Other skin problem 6.22 Chemicals, Drugs, and Medications 6.17 Blood Pain medications Blood transfusions Sleep medications Sickle cell disease Steroids Clotting or bleeding disorders Blood thinners Anemia (low red blood cell count) Beta blockers or clonidine Yes No Have you worn a respirator? If you've used a respirator, have you ever had any of the following problems while using a respirator? a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Trouble breathing f. Any other problem that interferes with your use of a respirator What type of respirator will you use? a. Disposable respirator (filter-mask, non- cartridge type only). b. Other type (for example, half- or full-face piece type, powered-air purifying, self-contained breathing apparatus (SCBA)). Describe the work you will be doing while you are using your respirator(s), including any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, gases):
Yes No Yes No Fractured bone that did not properly heal Enlarged spleen Osteomyelitis (bone infection) Low white blood cell count 6.15 Neurological Disorders Blood clots or need for blood thinners Seizures (fits) or Epilepsy Too many blood cells (polycythemia) Balance, walking or movement problems 6.18 Endocrine and Metabolic Passing out while at rest or with activity Diabetes Tremors Thyroid problems Muscular weakness Disease of the pituitary, adrenal, or parathyroid glands Paralysis of any limb Other hormone or nutrition problem Memory problems 6.19 Systemic Diseases and Miscellaneous Migraine or other chronic headaches Lupus, scleroderma, rheumatoid arthritis, or dermatomyositis Altered sensation or numbness Burn injury with ongoing problems Cerebral aneurysm Heat stress or other heat injury Multiple sclerosis 6.20 Tumors and Malignancies Muscular dystrophy Tumor, malignancy, or cancer Head injury 6.21 Psychiatric Conditions Bleeding in head or brain Depression or other mood disorders 6.16 Skin Anxiety Skin cancer Alcoholism Rashes Other substance abuse Skin grafts Other psychiatric condition Other skin problem 6.22 Chemicals, Drugs, and Medications 6.17 Blood Pain medications Blood transfusions Sleep medications Sickle cell disease Steroids Clotting or bleeding disorders Blood thinners Anemia (low red blood cell count) Beta blockers or clonidine Yes No Have you worn a respirator? If you've used a respirator, have you ever had any of the following problems while using a respirator? a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Trouble breathing f. Any other problem that interferes with your use of a respirator What type of respirator will you use? a. Disposable respirator (filter-mask, non- cartridge type only). b. Other type (for example, half- or full-face piece type, powered-air purifying, self-contained breathing apparatus (SCBA)). Describe the work you will be doing while you are using your respirator(s), including any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, gases):
firefighter-baseline-questionnaire.docx