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Submitted URL: http://pgs.prime-eme.com/Questionnaire/Hess/HessCorporationOffshoreMobileSurveillance
Effective URL: https://pgs.prime-eme.com/Questionnaire/Hess/HessCorporationOffshoreMobileSurveillance
Submission: On June 15 via manual from IN — Scanned from DE
Effective URL: https://pgs.prime-eme.com/Questionnaire/Hess/HessCorporationOffshoreMobileSurveillance
Submission: On June 15 via manual from IN — Scanned from DE
Form analysis 1 forms found in the DOM
POST /Questionnaire/Hess/HessCorporationOffshoreMobileSurveillance
<form action="/Questionnaire/Hess/HessCorporationOffshoreMobileSurveillance" method="post" id="prime-questionnaire" novalidate="novalidate">
<input data-val="true" data-val-number="The field TestTypeId must be a number." data-val-required="The TestTypeId field is required." id="Header_TestTypeId" name="Header.TestTypeId" type="hidden" value="10">
<input data-val="true" data-val-number="The field TestReasonId must be a number." data-val-required="The TestReasonId field is required." id="Header_TestReasonId" name="Header.TestReasonId" type="hidden" value="13">
<input data-val="true" data-val-number="The field ProjectCompanyJobId must be a number." data-val-required="The ProjectCompanyJobId field is required." id="Header_ProjectCompanyJobId" name="Header.ProjectCompanyJobId" type="hidden" value="9715">
<input data-val="true" data-val-number="The field Id must be a number." data-val-required="The Id field is required." id="FormTemplate_Id" name="FormTemplate.Id" type="hidden" value="109">
<script type="text/x-handlebars-template" id="checkboxGroup-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
{{#if title}}
<label name="title" class="control-label">{{title}}</label>
{{/if}}
{{#if question}}
<div>
<span name="question">{{question}}</span>
</div>
{{/if}}
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
{{#each options}}
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
{{#option}}
<input type="checkbox" class="question-yes" id="option-{{parentId}}-{{@index}}" value="{{value}}">
<label for="option-{{parentId}}-{{@index}}" name="optionName">{{name}}</label>
{{/option}}
</div>
</div>
{{/each}}
</div>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="dateinput-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label">
{{question}}
{{#if required}}
<span class="required" aria-required="true">*</span>
{{/if}}
</label>
</div>
<div class="col-sm-12">
<input name="dateinput-{{id}}" class="form-control .prime-masked ctrl-dateInput" type="text" value=""
data-mask="mm/dd/yyyy"
data-val="true"
data-val-date="This field must be a date." {{#if required}} data-val-required="true" {{/if}}>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="radioGroup-template"> <div class="questionnaire-questions">
<div class="row form-group">
{{#if title}}
<div class="col-xs-12 title">
<b>{{title}}</b>
{{#if required}}
<span class="required" aria-required="true">*</span>
{{/if}}
</div>
{{/if}}
<div class="form-group">
{{#if question}}
<div class="col-sm-12">
{{question}}
{{#if required}}
{{#unless title}}
<span class="required" aria-required="true">*</span>
{{/unless}}
{{/if}}
</div>
{{/if}}
{{#if required}}
{{#unless title}}
{{#unless question}}
<span class="required" aria-required="true">*</span>
{{/unless}}
{{/unless}}
{{/if}}
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-{{id}}">
<input id="radio-yes-{{id}}" name="yes-no-radio-group-{{id}}" type="radio" class="question-yes" value="true" {{#if required}} required {{/if}} />
<label for="radio-yes-{{id}}" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-{{id}}">
<input id="radio-no-{{id}}" name="yes-no-radio-group-{{id}}" type="radio" class="question-no" value="false" {{#if required}} required {{/if}}>
<label for="radio-no-{{id}}" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="section-header-template"> <div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header">
{{title}}
</h3>
<h5 name="description" class="section-description">{{question}}</h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="textArea-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label">
{{question}}
{{#if required}}
<span class="required " style="float: right" aria-required="true">*</span>
{{/if}}
</label>
</div>
<div class="col-sm-12">
<textarea name="text-{{id}}" placeholder="{{placeholder}}" class="form-control ctrl-textArea" rows="2" cols="20" {{#if required}} data-val="true" data-val-required="true"{{/if}}></textarea>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="textbox-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label">
{{question}}
{{#if required}}<span class="required " style="float: right" aria-required="true">*</span>{{/if}}
</label>
</div>
<div class="col-sm-12">
<input name="textbox-{{id}}" type="text" placeholder="{{placeholder}}" class="form-control ctrl-textbox" {{#if required}}data-val="true" data-val-required="true"{{/if}} />
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="picture-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label">
{{question}}
{{#if required}}<span class="required " style="float: right" aria-required="true">*</span>{{/if}}
</label>
{{#if required}}
<input name="placeholder" type="file" accept="image/*" class="ctrl-picture" required/>
{{else}}
<input name="placeholder" type="file" accept="image/*" class="ctrl-picture"/>
{{/if}}
<br/>
<img src="" height="200" alt="{{placeholder}}">
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="yesNoExplainRadioGroup-template"> <div class="questionnaire-questions">
<div class="row form-group">
{{#if title}}
<div class="col-sm-12 title">
<b>{{title}}</b>
{{#if required}}
<span class="required" aria-required="true">*</span>
{{/if}}
</div>
{{/if}}
<div class="form-group">
{{#if question}}
<div class="col-sm-12">
{{question}}
{{#if required}}
{{#unless title}}
<span class="required" aria-required="true">*</span>
{{/unless}}
{{/if}}
</div>
{{/if}}
{{#if required}}
{{#unless title}}
{{#unless question}}
<span class="required" aria-required="true">*</span>
{{/unless}}
{{/unless}}
{{/if}}
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{id}}" data-group-name="yes-no-radio-group-{{id}}">
<input id="radio_yes_{{id}}" name="yes-no-radio-group-{{id}}" type="radio" class="question-yes" value="true" {{#if required}} required {{/if}} />
<label for="radio_yes_{{id}}" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{id}}" data-group-name="yes-no-radio-group-{{id}}">
<input id="radio_no_{{id}}" name="yes-no-radio-group-{{id}}" type="radio" class="question-no" value="false" {{#if required}} required {{/if}}>
<label for="radio_no_{{id}}" class="control-label">No</label>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<textarea class="explanation-for form-control" id="explanation_{{id}}" name="explanation-{{id}}" placeholder="{{placeholder}}" data-driven-by=".yesNo-radio-{{id}} input[type=radio]" rows="3" cols="20" data-val="true" data-val-required="true"></textarea>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="checkboxExplain-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
{{#if title}}
<label name="title" class="control-label">{{title}}</label>
{{/if}}
{{#if question}}
<div>
<span name="question">{{question}}</span>
</div>
{{/if}}
</div>
<div class="col-sm-12">
<div class="ctrl-CHKBXEXPLN row row-vertical-offset checkbox-group-{{id}}">
{{#each options}}
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
{{#option}}
<input type="checkbox" class="question-yes" id="option-{{parentId}}-{{@index}}" value="{{value}}">
<label for="option-{{parentId}}-{{@index}}" name="optionName">{{name}}</label>
{{/option}}
</div>
</div>
{{/each}}
</div>
</div>
<div class="col-sm-12">
<textarea placeholder="{{placeholder}}" class="explanation-for form-control" cols="20" data-driven-by=".checkbox-group-{{id}} input[type=checkbox]"
id="questionnaire-checkbox-explanation-{{id}}" name="questionnaire-checkbox-explanation-{{id}}"
rows="3" data-val="true" data-val-required="true"></textarea>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="demographic-template"> <div class="col-sm-6 form-group questionnaire-questions">
<div class="">
<label name="title" class="control-label">
{{title}}
{{#if required}}<span class="required " style="float: right" aria-required="true"> *</span>{{/if}}
</label>
</div>
<div class="">
<input name="{{code}}" type="text" placeholder="{{placeholder}}" class="form-control ctrl-demographic" {{#if required}} data-val="true" data-val-required="true" {{/if}} />
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="altphone-template"> <div class="col-sm-6 form-group questionnaire-questions">
<div class="">
<label name="title" class="control-label">
{{title}}
{{#if required}}<span class="required " style="float: right" aria-required="true"> *</span>{{/if}}
</label>
</div>
<div class="">
<input name="{{code}}" type="text" placeholder="{{placeholder}}" data-mask="(999) 999-9999" class="form-control ctrl-altphone" {{#if required}} data-val="true" data-val-required="true" {{/if}} />
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="multiColumnRadioGroup-template">
{{#if title}}
<label name="title" class="control-label">{{title}}</label>
{{/if}}
{{#if question}}
<div>
<span name="question">{{question}}</span>
</div>
{{/if}}
<div class="form-group">
<div class="ctrl-MULTIRADIO row row-vertical-offset">
<div class="col-sm-6">
{{#each options1}}
<div class="{{#unless cssStyle}}col-sm-12{{/unless}} {{cssStyle}}">
<div class="form-group">
{{#option}}
<label name="optionName" class="control-label radio-option-label">{{name}}</label>
{{#if ../../required}}
<span class="required" aria-required="true">*</span>
{{/if}}
<br />
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{../../id}}" data-group-name="yes-no-radio-group-{{../../id}}-1-{{@index}}">
<input id="option-yes-{{../../id}}-1-{{@index}}" name="yes-no-radio-group-{{../../id}}-1-{{@index}}" type="radio" class="question-yes" value="true" {{#if ../../required}} required {{/if}} />
<label for="option-yes-{{../../id}}-1-{{@index}}" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{../../id}}" data-group-name="yes-no-radio-group-{{../../id}}-1-{{@index}}">
<input id="option-no-{{../../id}}-1-{{@index}}" name="yes-no-radio-group-{{../../id}}-1-{{@index}}" type="radio" class="question-no" value="false" {{#if ../../required}} required {{/if}}>
<label for="option-no-{{../../id}}-1-{{@index}}" class="control-label">No</label>
</div>
</div>
{{/option}}
</div>
</div>
{{/each}}
</div>
<div class="col-sm-6">
{{#each options2}}
<div class="{{#unless cssStyle}}col-sm-12{{/unless}} {{cssStyle}}">
<div class="form-group">
{{#option}}
<label name="optionName" class="control-label radio-option-label">{{name}}</label>
{{#if ../../required}}
<span class="required" aria-required="true">*</span>
{{/if}}
<br />
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{../../id}}" data-group-name="yes-no-radio-group-{{../../id}}-2-{{@index}}">
<input id="option-yes-{{../../id}}-2-{{@index}}" name="yes-no-radio-group-{{../../id}}-2-{{@index}}" type="radio" class="question-yes" value="true" {{#if ../../required}} required {{/if}} />
<label for="option-yes-{{../../id}}-2-{{@index}}" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-{{../../id}}" data-group-name="yes-no-radio-group-{{../../id}}-2-{{@index}}">
<input id="option-no-{{../../id}}-2-{{@index}}" name="yes-no-radio-group-{{../../id}}-2-{{@index}}" type="radio" class="question-no" value="false" {{#if ../../required}} required {{/if}}>
<label for="option-no-{{../../id}}-2-{{@index}}" class="control-label">No</label>
</div>
</div>
{{/option}}
</div>
</div>
{{/each}}
</div>
</div>
<div class="row">
<div class="col-xs-12">
<textarea class="explanation-for form-control" id="explanation_{{id}}" name="explanation-{{id}}" placeholder="{{placeholder}}" data-driven-by=".yesNo-radio-{{id}} input[type=radio]" rows="3" cols="20" data-val="true"
data-val-required="true"></textarea>
</div>
</div>
</div>
</script>
<script type="text/x-handlebars-template" id="timeinput-template"> <div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label">
{{question}}
{{#if required}}
<span class="required" aria-required="true">*</span>
{{/if}}
</label>
</div>
<div class="col-sm-12">
<input name="timeInput-{{id}}" class="form-control .prime-masked ctrl-timeInput" type="text" value=""
data-mask="h:s" data-placeholder="hh/mm"
data-val="true"
{{#if required}} data-val-required="true" {{/if}}>
</div>
</div>
</div>
</script>
<style>
body {
font-family: sans-serif;
line-height: 1.5;
letter-spacing: .5px;
}
</style>
<div id="_questionnaire">
<div class="well well-lg questionnaire-section">
<div class="questionnaire-header">
<div class="row">
<div class="col-xs-12">
<h3 class="section-header"> Employee Information </h3>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<hr class="divider">
</div>
</div>
</div>
<div class="questionnaire-body">
<div class="row">
<div class="col-xs-12">
<p> This form is used as a part of your occupational fitness evaluation. No medical evaluation or treatment is intended or being offered. Truthfulness is critical. Any false information may be subject to your employer's disciplinary
action, including job termination. </p>
</div>
</div>
</div>
<div class="questionnaire-questions">
<div class="row">
<div class="col-sm-3">
<div class="form-group">
<label for="Patient.FirstName" class="control-label">First Name: <span class="required " style="float: right" aria-required="true">*</span> </label>
<input type="text" name="Patient.FirstName" id="Patient.FirstName" value="" data-val="true" data-val-required="true" class="form-control ">
</div>
</div>
<div class="col-sm-3">
<div class="form-group">
<label for="Patient.MiddleName" class="control-label">Middle Name:</label>
<input type="text" name="Patient.MiddleName" id="Patient.MiddleName" value="" class="form-control ">
</div>
</div>
<div class="col-sm-3">
<div class="form-group">
<label for="Patient.LastName" class="control-label">Last Name: <span class="required " style="float: right" aria-required="true">*</span> </label>
<input type="text" name="Patient.LastName" id="Patient.LastName" value="" data-val="true" data-val-required="true" class="form-control ">
</div>
</div>
<div class="col-sm-3">
<div class="form-group">
<div class="col-sm-6 row">
<label class="control-label" for="Patient_Suffix">Suffix:</label> <span> </span>
<select id="Patient.Suffix" name="Patient.Suffix" class="form-control prime-required-field">
<option value=""></option>
<option value="JR">JR</option>
<option value="SR">SR</option>
<option value="II">II</option>
<option value="III">III</option>
<option value="IV">IV</option>
<option value="V">V</option>
</select>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-3">
<div class="form-group">
<label class="control-label" for="Patient_DateOfBirth">Date Of Birth:</label><span class="required" aria-required="true">*</span>
<input class="form-control .prime-masked" data-mask="mm/dd/yyyy" data-val="true" data-val-date="The field Date Of Birth must be a date." data-val-pastdate="Date of Birth must be in the past." data-val-pastdate-max="6/15/2023"
data-val-pastdate-min="6/15/1903" data-val-required="The Date Of Birth field is required." id="Patient_DateOfBirth" name="Patient.DateOfBirth" type="tel" value="">
<span class="field-validation-valid text-danger" data-valmsg-for="Patient.DateOfBirth" data-valmsg-replace="true"></span>
</div>
</div>
<div class="col-sm-3">
<label class="control-label" for="Patient_SSN">Social Security Number:</label><span class="required" aria-required="true">*</span>
<input class="form-control .prime-masked" data-mask="999-99-9999" data-val="true" data-val-required="The Social Security Number field is required." id="Patient_SSN" name="Patient.SSN" type="tel" value="">
</div>
<div class="col-sm-3">
<label class="control-label" for="Patient_ContactPhoneNumber">Contact Phone Number:</label><span class="required" aria-required="true">*</span>
<input class="form-control .prime-masked" data-mask="(999) 999-9999" data-val="true" data-val-required="The Contact Phone Number field is required." id="Patient_ContactPhoneNumber" name="Patient.ContactPhoneNumber" type="tel" value="">
</div>
</div>
</div>
</div>
<div class="well well-lg questionnaire-section">
<div class="row">
<div class="col-xs-12">
<h3 class="section-header"> Alternate Identifiers </h3>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<hr class="divider">
</div>
</div>
<div id="demographic-form" style="padding: 0 !important; margin-left:-15px; overflow-y:hidden;">
<div>
<div class="col-sm-6 form-group questionnaire-questions">
<div class="">
<label name="title" class="control-label"> Job Title </label>
</div>
<div class="">
<input name="JOBTITLE" type="text" placeholder="" class="form-control ctrl-demographic">
</div>
</div>
</div>
<div>
<div class="col-sm-6 form-group questionnaire-questions">
<div class="">
<label name="title" class="control-label"> Alternate Phone Number </label>
</div>
<div class="">
<input name="ALTPHONE" type="text" placeholder="" data-mask="(999) 999-9999" class="form-control ctrl-altphone">
</div>
</div>
</div>
</div>
</div>
<div id="questionnaire-form" class="well well-lg questionnaire-section">
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> Date </label>
</div>
<div class="col-sm-12">
<input name="dateinput-2526" class="form-control .prime-masked ctrl-dateInput" type="text" value="" data-mask="mm/dd/yyyy" data-val="true" data-val-date="This field must be a date.">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> Home Address </label>
</div>
<div class="col-sm-12">
<input name="textbox-2527" type="text" placeholder="" class="form-control ctrl-textbox">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> City </label>
</div>
<div class="col-sm-12">
<input name="textbox-2528" type="text" placeholder="" class="form-control ctrl-textbox">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> State </label>
</div>
<div class="col-sm-12">
<input name="textbox-2529" type="text" placeholder="" class="form-control ctrl-textbox">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> Employer </label>
</div>
<div class="col-sm-12">
<input name="textbox-2530" type="text" placeholder="" class="form-control ctrl-textbox">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Sex</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2531-0" value="Male">
<label for="option-2531-0" name="optionName">Male</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2531-1" value="Female">
<label for="option-2531-1" name="optionName">Female</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header"> Section 2 - Medical History Questionnaire </h3>
<h5 name="description" class="section-description"></h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Are you now taking, or have you ever taken any of the following within the past (3) months?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-0" value="Anyprescriptionpainmedications">
<label for="option-2533-0" name="optionName">Any prescription pain medications</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-1" value="Antidepressants">
<label for="option-2533-1" name="optionName">Antidepressants</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-2" value="Sleepingpill">
<label for="option-2533-2" name="optionName">Sleeping pill</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-3" value="Diureticorwaterpill">
<label for="option-2533-3" name="optionName">Diuretic or water pill</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-4" value="Insulinordiabetesmedicine">
<label for="option-2533-4" name="optionName">Insulin or diabetes medicine</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-5" value="Bloodpressuremedication">
<label for="option-2533-5" name="optionName">Blood pressure medication</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-6" value="Anticoagulant(bloodthinner)">
<label for="option-2533-6" name="optionName">Anticoagulant (blood thinner)</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-7" value="Stimulant/ADDmedication">
<label for="option-2533-7" name="optionName">Stimulant/ADD medication</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2533-8" value="Sedatives/Tranquilizers">
<label for="option-2533-8" name="optionName">Sedatives/Tranquilizers</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> Please list all MEDICATIONS you are currently taking: </label>
</div>
<div class="col-sm-12">
<textarea name="text-2534" placeholder="" class="form-control ctrl-textArea" rows="2" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<label name="title" class="control-label">Have you had any occupational illness or injuries at your current/last job? If yes, explain.</label>
<div class="form-group">
<div class="ctrl-MULTIRADIO row row-vertical-offset">
<div class="col-sm-6">
<div class="col-sm-12 ">
<div class="form-group">
<label name="optionName" class="control-label radio-option-label"></label>
<br>
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2537" data-group-name="yes-no-radio-group-2537-1-0">
<input id="option-yes-2537-1-0" name="yes-no-radio-group-2537-1-0" type="radio" class="question-yes" value="true">
<label for="option-yes-2537-1-0" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2537" data-group-name="yes-no-radio-group-2537-1-0">
<input id="option-no-2537-1-0" name="yes-no-radio-group-2537-1-0" type="radio" class="question-no" value="false">
<label for="option-no-2537-1-0" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
<div class="col-sm-6">
</div>
</div>
<div class="row" style="display: none;">
<div class="col-xs-12" style="display: none;">
<textarea class="explanation-for form-control" id="explanation_2537" name="explanation-2537" placeholder="" data-driven-by=".yesNo-radio-2537 input[type=radio]" rows="3" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<label name="title" class="control-label">Have you ever had any occupational illness or injuries at any previous job? If yes, explain.</label>
<div class="form-group">
<div class="ctrl-MULTIRADIO row row-vertical-offset">
<div class="col-sm-6">
<div class="col-sm-12 ">
<div class="form-group">
<label name="optionName" class="control-label radio-option-label"></label>
<br>
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2538" data-group-name="yes-no-radio-group-2538-1-0">
<input id="option-yes-2538-1-0" name="yes-no-radio-group-2538-1-0" type="radio" class="question-yes" value="true">
<label for="option-yes-2538-1-0" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2538" data-group-name="yes-no-radio-group-2538-1-0">
<input id="option-no-2538-1-0" name="yes-no-radio-group-2538-1-0" type="radio" class="question-no" value="false">
<label for="option-no-2538-1-0" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
<div class="col-sm-6">
</div>
</div>
<div class="row" style="display: none;">
<div class="col-xs-12" style="display: none;">
<textarea class="explanation-for form-control" id="explanation_2538" name="explanation-2538" placeholder="" data-driven-by=".yesNo-radio-2538 input[type=radio]" rows="3" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you EVER had any of the following?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-0" value="Receivedlongtermmedicaltreatment?">
<label for="option-2539-0" name="optionName">Received long term medical treatment?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-1" value="Anymedical/physicaltherapy/chiropractortreatmentforspinepain,kneepain,orshoulderpain?">
<label for="option-2539-1" name="optionName">Any medical/physical therapy/chiropractor treatment for spine pain, knee pain, or shoulder pain?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-2" value="CT/CATScanorMRI?">
<label for="option-2539-2" name="optionName">CT/CAT Scan or MRI?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-3" value="Hadanoperation?">
<label for="option-2539-3" name="optionName">Had an operation?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-4" value="Filedforanykindofdisability?">
<label for="option-2539-4" name="optionName">Filed for any kind of disability?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-5" value="Reportedajob-relatedillnessorinjury?">
<label for="option-2539-5" name="optionName">Reported a job-related illness or injury?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-6" value="Receivedanydisabilitypay?">
<label for="option-2539-6" name="optionName">Received any disability pay?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-7" value="Exposuretobenzene,lead,arsenic,mercury,silica,orasbestos?">
<label for="option-2539-7" name="optionName">Exposure to benzene, lead, arsenic, mercury, silica, or asbestos?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-8" value="Exposuretodegreasers,solvents,insecticides,fungicides?">
<label for="option-2539-8" name="optionName">Exposure to degreasers, solvents, insecticides, fungicides?</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2539-9" value="Exposuretoanyotherknownhazardouschemicalsorcompounds?">
<label for="option-2539-9" name="optionName">Exposure to any other known hazardous chemicals or compounds?</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> If yes to any of the above, please Explain. </label>
</div>
<div class="col-sm-12">
<textarea name="text-2540" placeholder="" class="form-control ctrl-textArea" rows="2" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you EVER been diagnosed with or sought treatment for the following:</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-0" value="Headinjuryorconcussion">
<label for="option-2541-0" name="optionName">Head injury or concussion</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-1" value="Seizure,fits,orconvulsions">
<label for="option-2541-1" name="optionName">Seizure, fits, or convulsions</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-2" value="Fainting">
<label for="option-2541-2" name="optionName">Fainting</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-3" value="Eyeproblemsorinjury">
<label for="option-2541-3" name="optionName">Eye problems or injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-4" value="Eartroubleorinjury">
<label for="option-2541-4" name="optionName">Ear trouble or injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-5" value="Hearingtrouble">
<label for="option-2541-5" name="optionName">Hearing trouble</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-6" value="Jointsurgery/scope">
<label for="option-2541-6" name="optionName">Joint surgery/scope</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-7" value="Paralysis">
<label for="option-2541-7" name="optionName">Paralysis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-8" value="Heatstroke">
<label for="option-2541-8" name="optionName">Heat stroke</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-9" value="Chestpain">
<label for="option-2541-9" name="optionName">Chest pain</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-10" value="Hearttrouble">
<label for="option-2541-10" name="optionName">Heart trouble</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-11" value="Irregularheartbeat">
<label for="option-2541-11" name="optionName">Irregular heartbeat</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-12" value="Highbloodpressure">
<label for="option-2541-12" name="optionName">High blood pressure</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-13" value="Shortnessofbreath">
<label for="option-2541-13" name="optionName">Shortness of breath</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-14" value="Asthmaorwheezing">
<label for="option-2541-14" name="optionName">Asthma or wheezing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-15" value="Jointpainorswelling">
<label for="option-2541-15" name="optionName">Joint pain or swelling</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-16" value="Frequentbronchitis">
<label for="option-2541-16" name="optionName">Frequent bronchitis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-17" value="Neckpainorinjury">
<label for="option-2541-17" name="optionName">Neck pain or injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-18" value="Tuberculosis">
<label for="option-2541-18" name="optionName">Tuberculosis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-19" value="NeckPainorInjury">
<label for="option-2541-19" name="optionName">Neck Pain or Injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-20" value="Backpainorinjury">
<label for="option-2541-20" name="optionName">Back pain or injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-21" value="AbnormalX-ray">
<label for="option-2541-21" name="optionName">Abnormal X-ray</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-22" value="Bonesurgery">
<label for="option-2541-22" name="optionName">Bone surgery</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-23" value="Stroke">
<label for="option-2541-23" name="optionName">Stroke</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-24" value="Bursitis">
<label for="option-2541-24" name="optionName">Bursitis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-25" value="Pneumonia">
<label for="option-2541-25" name="optionName">Pneumonia</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-26" value="Diabetes">
<label for="option-2541-26" name="optionName">Diabetes</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-27" value="KidneyTrouble">
<label for="option-2541-27" name="optionName">Kidney Trouble</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-28" value="Hernia">
<label for="option-2541-28" name="optionName">Hernia</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-29" value="Livertrouble">
<label for="option-2541-29" name="optionName">Liver trouble</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-30" value="Cancerortumor">
<label for="option-2541-30" name="optionName">Cancer or tumor</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-31" value="Easybruising">
<label for="option-2541-31" name="optionName">Easy bruising</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-32" value="Poorhealing">
<label for="option-2541-32" name="optionName">Poor healing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-33" value="Severedepression">
<label for="option-2541-33" name="optionName">Severe depression</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-34" value="Emotionalproblems">
<label for="option-2541-34" name="optionName">Emotional problems</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-35" value="Fearofheights">
<label for="option-2541-35" name="optionName">Fear of heights</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-36" value="Alcoholism">
<label for="option-2541-36" name="optionName">Alcoholism</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-37" value="Drugaddiction">
<label for="option-2541-37" name="optionName">Drug addiction</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2541-38" value="Painmanagement">
<label for="option-2541-38" name="optionName">Pain management</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> If YES to any of the above questions, please explain. </label>
</div>
<div class="col-sm-12">
<textarea name="text-2542" placeholder="" class="form-control ctrl-textArea" rows="2" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header"> Section 3 – OSHA Respirator Medical Evaluation Questionnaire </h3>
<h5 name="description" class="section-description"></h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-xs-12 title">
<b>Do you currently smoke tobacco, or have you smoked tobacco in the last month?</b>
</div>
<div class="form-group">
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-2544">
<input id="radio-yes-2544" name="yes-no-radio-group-2544" type="radio" class="question-yes" value="true">
<label for="radio-yes-2544" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-2544">
<input id="radio-no-2544" name="yes-no-radio-group-2544" type="radio" class="question-no" value="false">
<label for="radio-no-2544" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you ever had any of the following conditions?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2545-0" value="Seizures">
<label for="option-2545-0" name="optionName">Seizures</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2545-1" value="Diabetes">
<label for="option-2545-1" name="optionName">Diabetes</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2545-2" value="Allergicreactionsthatinterferewithyourbreathing">
<label for="option-2545-2" name="optionName">Allergic reactions that interfere with your breathing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2545-3" value="Claustrophobia">
<label for="option-2545-3" name="optionName">Claustrophobia</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2545-4" value="Troublesmellingodors">
<label for="option-2545-4" name="optionName">Trouble smelling odors</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you ever had any of the following pulmonary or lung problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-0" value="Asbestosis">
<label for="option-2546-0" name="optionName">Asbestosis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-1" value="Asthma">
<label for="option-2546-1" name="optionName">Asthma</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-2" value="Chronicbronchitis">
<label for="option-2546-2" name="optionName">Chronic bronchitis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-3" value="Emphysema">
<label for="option-2546-3" name="optionName">Emphysema</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-4" value="Pneumonia">
<label for="option-2546-4" name="optionName">Pneumonia</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-5" value="Tuberculosis">
<label for="option-2546-5" name="optionName">Tuberculosis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-6" value="Silicosis">
<label for="option-2546-6" name="optionName">Silicosis</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-7" value="Pneumothorax">
<label for="option-2546-7" name="optionName">Pneumothorax</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-8" value="Lungcancer">
<label for="option-2546-8" name="optionName">Lung cancer</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-9" value="Brokenribs">
<label for="option-2546-9" name="optionName">Broken ribs</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-10" value="Anychestinjuriesorsurgeries">
<label for="option-2546-10" name="optionName">Any chest injuries or surgeries</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2546-11" value="Anyotherlungproblem">
<label for="option-2546-11" name="optionName">Any other lung problem</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Do you currently have any of the following symptoms of pulmonary or lung illness?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-0" value="Shortnessofbreath">
<label for="option-2547-0" name="optionName">Shortness of breath</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-1" value="Shortnessofbreathwhenwalkingfastonlevelgroundorwalkinginaslighthillorincline">
<label for="option-2547-1" name="optionName">Shortness of breath when walking fast on level ground or walking in a slight hill or incline</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-2" value="Shortnessofbreathwhenwalkingwithotherpeopleatanordinarypaceonlevelground">
<label for="option-2547-2" name="optionName">Shortness of breath when walking with other people at an ordinary pace on level ground</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-3" value="Muststopforbreathwhenwalkingatyourownpaceonlevelground.">
<label for="option-2547-3" name="optionName">Must stop for breath when walking at your own pace on level ground.</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-4" value="Shortnessofbreathwhenwashingordressing">
<label for="option-2547-4" name="optionName">Shortness of breath when washing or dressing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-5" value="Shortnessofbreaththatinterfereswithyourjob">
<label for="option-2547-5" name="optionName">Shortness of breath that interferes with your job</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-6" value="Coughingthatproducesphlegm(thicksputum)">
<label for="option-2547-6" name="optionName">Coughing that produces phlegm (thick sputum)</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-7" value="Coughingthatwakesyouearlyinthemorningoratnight">
<label for="option-2547-7" name="optionName">Coughing that wakes you early in the morning or at night</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-8" value="Coughingthatoccursmostlywhenyouarelayingdown">
<label for="option-2547-8" name="optionName">Coughing that occurs mostly when you are laying down</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-9" value="Coughingupbloodinthelastmonth">
<label for="option-2547-9" name="optionName">Coughing up blood in the last month</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-10" value="Wheezing">
<label for="option-2547-10" name="optionName">Wheezing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-11" value="Wheezingthatinterfereswithyourjob">
<label for="option-2547-11" name="optionName">Wheezing that interferes with your job</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-12" value="Chestpainwhenyoubreathedeeply">
<label for="option-2547-12" name="optionName">Chest pain when you breathe deeply</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2547-13" value="Anyothersymptomsthatyouthinkmayberelatedtolungproblems">
<label for="option-2547-13" name="optionName">Any other symptoms that you think may be related to lung problems</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you ever had any of the following cardiovascular problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-0" value="Heartattack">
<label for="option-2548-0" name="optionName">Heart attack</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-1" value="Stroke">
<label for="option-2548-1" name="optionName">Stroke</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-2" value="Angina">
<label for="option-2548-2" name="optionName">Angina</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-3" value="Heartfailure">
<label for="option-2548-3" name="optionName">Heart failure</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-4" value="Swellinginyourlegsorfeet(notcausedbywalking)">
<label for="option-2548-4" name="optionName">Swelling in your legs or feet (not caused by walking)</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-5" value="Heartarrhythmia(heartbeatingirregularly)">
<label for="option-2548-5" name="optionName">Heart arrhythmia (heart beating irregularly)</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-6" value="Highbloodpressure">
<label for="option-2548-6" name="optionName">High blood pressure</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2548-7" value="Anyotherheartproblemthatyou’vebeentoldabout">
<label for="option-2548-7" name="optionName">Any other heart problem that you’ve been told about</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you ever had any of the following cardiovascular or heart symptoms?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-0" value="Frequentpainortightnessinyourchest">
<label for="option-2549-0" name="optionName">Frequent pain or tightness in your chest</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-1" value="Painortightnessinyourchestduringphysicalactivity">
<label for="option-2549-1" name="optionName">Pain or tightness in your chest during physical activity</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-2" value="Painortightnessinyourchestthatinterfereswithyourjob">
<label for="option-2549-2" name="optionName">Pain or tightness in your chest that interferes with your job</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-3" value="Inthepasttwoyears,haveyounoticedyourheartskippingormissingabeat">
<label for="option-2549-3" name="optionName">In the past two years, have you noticed your heart skipping or missing a beat</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-4" value="Heartburnorindigestionthatisnotrelatedtoeating">
<label for="option-2549-4" name="optionName">Heartburn or indigestion that is not related to eating</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2549-5" value="Anyothersymptomsthatyouthinkmayberelatedtoheartorcirculationproblems">
<label for="option-2549-5" name="optionName">Any other symptoms that you think may be related to heart or circulation problems</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Do you currently take medication for any of the following problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2550-0" value="Breathingorlungproblems">
<label for="option-2550-0" name="optionName">Breathing or lung problems</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2550-1" value="Hearttrouble">
<label for="option-2550-1" name="optionName">Heart trouble</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2550-2" value="Bloodpressure">
<label for="option-2550-2" name="optionName">Blood pressure</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2550-3" value="Seizures">
<label for="option-2550-3" name="optionName">Seizures</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">If you’ve used a respirator, have you ever had any of the following problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2551-0" value="Eyeirritation">
<label for="option-2551-0" name="optionName">Eye irritation</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2551-1" value="Skinallergiesorrashes">
<label for="option-2551-1" name="optionName">Skin allergies or rashes</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2551-2" value="Anxiety">
<label for="option-2551-2" name="optionName">Anxiety</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2551-3" value="Generalweaknessorfatigue">
<label for="option-2551-3" name="optionName">General weakness or fatigue</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2551-4" value="Anyotherproblemthatinterfereswithyouruseofarespirator">
<label for="option-2551-4" name="optionName">Any other problem that interferes with your use of a respirator</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-xs-12 title">
<b>Would you like to talk to the healthcare professional who will review this questionnaire about your answers to this questionnaire?</b>
</div>
<div class="form-group">
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-2552">
<input id="radio-yes-2552" name="yes-no-radio-group-2552" type="radio" class="question-yes" value="true">
<label for="radio-yes-2552" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-2552">
<input id="radio-no-2552" name="yes-no-radio-group-2552" type="radio" class="question-no" value="false">
<label for="radio-no-2552" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-xs-12 title">
<b>Have you ever lost vision in either eye (temporarily or permanently)</b>
</div>
<div class="form-group">
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-2553">
<input id="radio-yes-2553" name="yes-no-radio-group-2553" type="radio" class="question-yes" value="true">
<label for="radio-yes-2553" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-2553">
<input id="radio-no-2553" name="yes-no-radio-group-2553" type="radio" class="question-no" value="false">
<label for="radio-no-2553" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Do you currently have any of the following vision problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2554-0" value="Wearcontactlenses">
<label for="option-2554-0" name="optionName">Wear contact lenses</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2554-1" value="Wearglasses">
<label for="option-2554-1" name="optionName">Wear glasses</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2554-2" value="Colorblind">
<label for="option-2554-2" name="optionName">Color blind</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2554-3" value="Anyothereyeorvisionproblem">
<label for="option-2554-3" name="optionName">Any other eye or vision problem</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-xs-12 title">
<b>Have you ever had an injury to your ears, including a broken ear drum?</b>
</div>
<div class="form-group">
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-2555">
<input id="radio-yes-2555" name="yes-no-radio-group-2555" type="radio" class="question-yes" value="true">
<label for="radio-yes-2555" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-2555">
<input id="radio-no-2555" name="yes-no-radio-group-2555" type="radio" class="question-no" value="false">
<label for="radio-no-2555" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Do you currently have any of the following hearing problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2556-0" value="Difficultyhearing">
<label for="option-2556-0" name="optionName">Difficulty hearing</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2556-1" value="Wearingahearingaid">
<label for="option-2556-1" name="optionName">Wearing a hearing aid</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2556-2" value="Anyotherhearingproblem">
<label for="option-2556-2" name="optionName">Any other hearing problem</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-xs-12 title">
<b>Have you ever had a back injury?</b>
</div>
<div class="form-group">
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group" data-group-name="yes-no-radio-group-2557">
<input id="radio-yes-2557" name="yes-no-radio-group-2557" type="radio" class="question-yes" value="true">
<label for="radio-yes-2557" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group MedicalHistory_Medications" data-group-name="yes-no-radio-group-2557">
<input id="radio-no-2557" name="yes-no-radio-group-2557" type="radio" class="question-no" value="false">
<label for="radio-no-2557" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Do you currently have any of the following musculoskeletal problems?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-0" value="Weaknessinanyofyourarms,hands,legs,orfeet">
<label for="option-2558-0" name="optionName">Weakness in any of your arms, hands, legs, or feet</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-1" value="Backpain">
<label for="option-2558-1" name="optionName">Back pain</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-2" value="Difficultyfillymovingyourarmsandlegs">
<label for="option-2558-2" name="optionName">Difficulty filly moving your arms and legs</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-3" value="Painorstiffnesswhenyouleanforwardorbackwardatthewaist">
<label for="option-2558-3" name="optionName">Pain or stiffness when you lean forward or backward at the waist</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-4" value="Difficultyfullymovingyourheadupanddown">
<label for="option-2558-4" name="optionName">Difficulty fully moving your head up and down</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-5" value="Difficultyfullymovingyourheadsidetoside">
<label for="option-2558-5" name="optionName">Difficulty fully moving your head side to side</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-6" value="Difficultybendingatyourknees">
<label for="option-2558-6" name="optionName">Difficulty bending at your knees</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-7" value="Difficultysquattingtotheground">
<label for="option-2558-7" name="optionName">Difficulty squatting to the ground</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-8" value="Climbingaflightofstairsoraladdercarryingmorethan25lbs">
<label for="option-2558-8" name="optionName">Climbing a flight of stairs or a ladder carrying more than 25 lbs</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2558-9" value="Anyothermuscleorskeletalproblemthatinterfereswitharespirator">
<label for="option-2558-9" name="optionName">Any other muscle or skeletal problem that interferes with a respirator</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header"> Section 4 – Otologic History </h3>
<h5 name="description" class="section-description"></h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="title" class="control-label">Have you ever had any of the following conditions?</label>
</div>
<div class="col-sm-12">
<div class="ctrl-CHCKBXGRP row row-vertical-offset">
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-0" value="Noisesinears(Ringing,buzzing,orhumming)">
<label for="option-2560-0" name="optionName">Noises in ears (Ringing, buzzing, or humming)</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-1" value="Dizziness">
<label for="option-2560-1" name="optionName">Dizziness</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-2" value="Paininleftorrightear">
<label for="option-2560-2" name="optionName">Pain in left or right ear</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-3" value="Fluctuating,sudden,orrapidhearingloss">
<label for="option-2560-3" name="optionName">Fluctuating, sudden, or rapid hearing loss</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-4" value="Earinfections">
<label for="option-2560-4" name="optionName">Ear infections</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-5" value="Haveyoubeenseenbyanear,nose,andthroatphysician">
<label for="option-2560-5" name="optionName">Have you been seen by an ear, nose, and throat physician</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-6" value="Haveyoueverhadearsurgery">
<label for="option-2560-6" name="optionName">Have you ever had ear surgery</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-7" value="Haveyoueverhadaheadinjury">
<label for="option-2560-7" name="optionName">Have you ever had a head injury</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-8" value="Haveyoubeenexposedtogunfire">
<label for="option-2560-8" name="optionName">Have you been exposed to gunfire</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-9" value="Haveyouworkedonjobswithhighnoiselevels">
<label for="option-2560-9" name="optionName">Have you worked on jobs with high noise levels</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-10" value="Familyhistoryofhearingloss">
<label for="option-2560-10" name="optionName">Family history of hearing loss</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-11" value="Measles">
<label for="option-2560-11" name="optionName">Measles</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-12" value="Mumps">
<label for="option-2560-12" name="optionName">Mumps</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-13" value="Chickenpox">
<label for="option-2560-13" name="optionName">Chicken pox</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-14" value="Scarletfever">
<label for="option-2560-14" name="optionName">Scarlet fever</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-15" value="Diphtheria">
<label for="option-2560-15" name="optionName">Diphtheria</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-16" value="Haveyouevertakenlargedosesofantibiotics">
<label for="option-2560-16" name="optionName">Have you ever taken large doses of antibiotics</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-17" value="Doyoupresentlywearahearingaid">
<label for="option-2560-17" name="optionName">Do you presently wear a hearing aid</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-18" value="Haveyoubeenawayfromjobnoisefor14to16hours">
<label for="option-2560-18" name="optionName">Have you been away from job noise for 14 to 16 hours</label>
</div>
</div>
<div class="col-sm-6">
<div class="checkbox questionnaire-checkbox checkbox-primary prime-checkbox-group">
<input type="checkbox" class="question-yes" id="option-2560-19" value="Whenworkinginhighnoisearea,doyouwearhearingprotection?">
<label for="option-2560-19" name="optionName">When working in high noise area, do you wear hearing protection?</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div>
<span name="question">Years of military experience? If yes, please list branch and job.</span>
</div>
<div class="form-group">
<div class="ctrl-MULTIRADIO row row-vertical-offset">
<div class="col-sm-6">
<div class="col-sm-12 ">
<div class="form-group">
<label name="optionName" class="control-label radio-option-label"></label>
<br>
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2561" data-group-name="yes-no-radio-group-2561-1-0">
<input id="option-yes-2561-1-0" name="yes-no-radio-group-2561-1-0" type="radio" class="question-yes" value="true">
<label for="option-yes-2561-1-0" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2561" data-group-name="yes-no-radio-group-2561-1-0">
<input id="option-no-2561-1-0" name="yes-no-radio-group-2561-1-0" type="radio" class="question-no" value="false">
<label for="option-no-2561-1-0" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
<div class="col-sm-6">
</div>
</div>
<div class="row" style="display: none;">
<div class="col-xs-12" style="display: none;">
<textarea class="explanation-for form-control" id="explanation_2561" name="explanation-2561" placeholder="" data-driven-by=".yesNo-radio-2561 input[type=radio]" rows="3" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<div>
<span name="question">Do you have any noisy hobbies? If yes, please explain.</span>
</div>
<div class="form-group">
<div class="ctrl-MULTIRADIO row row-vertical-offset">
<div class="col-sm-6">
<div class="col-sm-12 ">
<div class="form-group">
<label name="optionName" class="control-label radio-option-label"></label>
<br>
<div class="col-sm-12">
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2562" data-group-name="yes-no-radio-group-2562-1-0">
<input id="option-yes-2562-1-0" name="yes-no-radio-group-2562-1-0" type="radio" class="question-yes" value="true">
<label for="option-yes-2562-1-0" class="control-label">Yes</label>
</div>
<div class="form-group radio questionnaire-radio radio-primary prime-radio-group yesNo-radio-2562" data-group-name="yes-no-radio-group-2562-1-0">
<input id="option-no-2562-1-0" name="yes-no-radio-group-2562-1-0" type="radio" class="question-no" value="false">
<label for="option-no-2562-1-0" class="control-label">No</label>
</div>
</div>
</div>
</div>
</div>
<div class="col-sm-6">
</div>
</div>
<div class="row" style="display: none;">
<div class="col-xs-12" style="display: none;">
<textarea class="explanation-for form-control" id="explanation_2562" name="explanation-2562" placeholder="" data-driven-by=".yesNo-radio-2562 input[type=radio]" rows="3" cols="20"></textarea>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header"> Section 5 – Release of Medical Information </h3>
<h5 name="description" class="section-description"></h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<label name="question" class="control-label"> Email Address that I would like my test results sent to: </label>
</div>
<div class="col-sm-12">
<input name="textbox-2569" type="text" placeholder="" class="form-control ctrl-textbox">
</div>
</div>
</div>
</div>
<div>
<div class="questionnaire-header">
<div class="row">
<div class="col-sm-12">
<h3 class="section-header ctrl-header">
</h3>
<h5 name="description" class="section-description">I give permission for Prime Occupational Medicine to release my annual medical test reports to my personal email address. Prime will send a “test” email, to confirm that the address is
correct. I will reply with my full name and date of birth to confirm the email address is valid. I understand and accept the security risks associated with emailed records, and hereby release Prime Occupational Medicine and Shintech
from any loss associated with the email of my records.</h5>
<div class="row">
<div class="col-sm-12">
<hr class="divider">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="well well-lg questionnaire-section">
<div class="questionnaire-header">
<div class="row">
<div class="col-xs-12">
<h3 class="section-header"> Confirmation </h3>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<hr class="divider">
</div>
</div>
</div>
<div class="questionnaire-questions">
<div class="row form-group">
<div class="col-sm-12">
<b></b>
</div>
</div>
<div class="row form-group">
<div class="col-sm-3">
<label class="control-label" for="EmployeeSignatureName">E-Signature</label> <span class="required" aria-required="true">*</span>
<input class="form-control" data-val="true" data-val-required="The E-Signature field is required." id="EmployeeSignatureName" name="EmployeeSignatureName" placeholder="" type="text" value="">
<small class="text-muted hidden-print">e.g. John Doe</small>
</div>
<div class="col-sm-9 validation-inline">
<span class="field-validation-valid text-danger" data-valmsg-for="EmployeeSignatureName" data-valmsg-replace="true" placeholder=""></span>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-12 text-right" id="submission">
<span class="btn btn-success form-submit" role="button" tabindex="0" data-bind="click: SubmitQuestionnaire">
<i class="fa fa-share"></i> Submit to Prime </span>
</div>
</div>
</form>Text Content
* Log in PRIME OCCUPATIONAL MEDICINE | HESS - HESS CORPORATION - 2023 OFFSHORE MOBILE SURVEILLANCE EMPLOYEE INFORMATION -------------------------------------------------------------------------------- This form is used as a part of your occupational fitness evaluation. No medical evaluation or treatment is intended or being offered. Truthfulness is critical. Any false information may be subject to your employer's disciplinary action, including job termination. First Name: * Middle Name: Last Name: * Suffix: JR SR II III IV V Date Of Birth:* Social Security Number:* Contact Phone Number:* ALTERNATE IDENTIFIERS -------------------------------------------------------------------------------- Job Title Alternate Phone Number Date Home Address City State Employer Sex Male Female SECTION 2 - MEDICAL HISTORY QUESTIONNAIRE -------------------------------------------------------------------------------- Are you now taking, or have you ever taken any of the following within the past (3) months? Any prescription pain medications Antidepressants Sleeping pill Diuretic or water pill Insulin or diabetes medicine Blood pressure medication Anticoagulant (blood thinner) Stimulant/ADD medication Sedatives/Tranquilizers Please list all MEDICATIONS you are currently taking: Have you had any occupational illness or injuries at your current/last job? If yes, explain. Yes No Have you ever had any occupational illness or injuries at any previous job? If yes, explain. Yes No Have you EVER had any of the following? Received long term medical treatment? Any medical/physical therapy/chiropractor treatment for spine pain, knee pain, or shoulder pain? CT/CAT Scan or MRI? Had an operation? Filed for any kind of disability? Reported a job-related illness or injury? Received any disability pay? Exposure to benzene, lead, arsenic, mercury, silica, or asbestos? Exposure to degreasers, solvents, insecticides, fungicides? Exposure to any other known hazardous chemicals or compounds? If yes to any of the above, please Explain. Have you EVER been diagnosed with or sought treatment for the following: Head injury or concussion Seizure, fits, or convulsions Fainting Eye problems or injury Ear trouble or injury Hearing trouble Joint surgery/scope Paralysis Heat stroke Chest pain Heart trouble Irregular heartbeat High blood pressure Shortness of breath Asthma or wheezing Joint pain or swelling Frequent bronchitis Neck pain or injury Tuberculosis Neck Pain or Injury Back pain or injury Abnormal X-ray Bone surgery Stroke Bursitis Pneumonia Diabetes Kidney Trouble Hernia Liver trouble Cancer or tumor Easy bruising Poor healing Severe depression Emotional problems Fear of heights Alcoholism Drug addiction Pain management If YES to any of the above questions, please explain. SECTION 3 – OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE -------------------------------------------------------------------------------- Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No Have you ever had any of the following conditions? Seizures Diabetes Allergic reactions that interfere with your breathing Claustrophobia Trouble smelling odors Have you ever had any of the following pulmonary or lung problems? Asbestosis Asthma Chronic bronchitis Emphysema Pneumonia Tuberculosis Silicosis Pneumothorax Lung cancer Broken ribs Any chest injuries or surgeries Any other lung problem Do you currently have any of the following symptoms of pulmonary or lung illness? Shortness of breath Shortness of breath when walking fast on level ground or walking in a slight hill or incline Shortness of breath when walking with other people at an ordinary pace on level ground Must stop for breath when walking at your own pace on level ground. Shortness of breath when washing or dressing Shortness of breath that interferes with your job Coughing that produces phlegm (thick sputum) Coughing that wakes you early in the morning or at night Coughing that occurs mostly when you are laying down Coughing up blood in the last month Wheezing Wheezing that interferes with your job Chest pain when you breathe deeply Any other symptoms that you think may be related to lung problems Have you ever had any of the following cardiovascular problems? Heart attack Stroke Angina Heart failure Swelling in your legs or feet (not caused by walking) Heart arrhythmia (heart beating irregularly) High blood pressure Any other heart problem that you’ve been told about Have you ever had any of the following cardiovascular or heart symptoms? Frequent pain or tightness in your chest Pain or tightness in your chest during physical activity Pain or tightness in your chest that interferes with your job In the past two years, have you noticed your heart skipping or missing a beat Heartburn or indigestion that is not related to eating Any other symptoms that you think may be related to heart or circulation problems Do you currently take medication for any of the following problems? Breathing or lung problems Heart trouble Blood pressure Seizures If you’ve used a respirator, have you ever had any of the following problems? Eye irritation Skin allergies or rashes Anxiety General weakness or fatigue Any other problem that interferes with your use of a respirator Would you like to talk to the healthcare professional who will review this questionnaire about your answers to this questionnaire? Yes No Have you ever lost vision in either eye (temporarily or permanently) Yes No Do you currently have any of the following vision problems? Wear contact lenses Wear glasses Color blind Any other eye or vision problem Have you ever had an injury to your ears, including a broken ear drum? Yes No Do you currently have any of the following hearing problems? Difficulty hearing Wearing a hearing aid Any other hearing problem Have you ever had a back injury? Yes No Do you currently have any of the following musculoskeletal problems? Weakness in any of your arms, hands, legs, or feet Back pain Difficulty filly moving your arms and legs Pain or stiffness when you lean forward or backward at the waist Difficulty fully moving your head up and down Difficulty fully moving your head side to side Difficulty bending at your knees Difficulty squatting to the ground Climbing a flight of stairs or a ladder carrying more than 25 lbs Any other muscle or skeletal problem that interferes with a respirator SECTION 4 – OTOLOGIC HISTORY -------------------------------------------------------------------------------- Have you ever had any of the following conditions? Noises in ears (Ringing, buzzing, or humming) Dizziness Pain in left or right ear Fluctuating, sudden, or rapid hearing loss Ear infections Have you been seen by an ear, nose, and throat physician Have you ever had ear surgery Have you ever had a head injury Have you been exposed to gunfire Have you worked on jobs with high noise levels Family history of hearing loss Measles Mumps Chicken pox Scarlet fever Diphtheria Have you ever taken large doses of antibiotics Do you presently wear a hearing aid Have you been away from job noise for 14 to 16 hours When working in high noise area, do you wear hearing protection? Years of military experience? If yes, please list branch and job. Yes No Do you have any noisy hobbies? If yes, please explain. Yes No SECTION 5 – RELEASE OF MEDICAL INFORMATION -------------------------------------------------------------------------------- Email Address that I would like my test results sent to: I GIVE PERMISSION FOR PRIME OCCUPATIONAL MEDICINE TO RELEASE MY ANNUAL MEDICAL TEST REPORTS TO MY PERSONAL EMAIL ADDRESS. PRIME WILL SEND A “TEST” EMAIL, TO CONFIRM THAT THE ADDRESS IS CORRECT. I WILL REPLY WITH MY FULL NAME AND DATE OF BIRTH TO CONFIRM THE EMAIL ADDRESS IS VALID. I UNDERSTAND AND ACCEPT THE SECURITY RISKS ASSOCIATED WITH EMAILED RECORDS, AND HEREBY RELEASE PRIME OCCUPATIONAL MEDICINE AND SHINTECH FROM ANY LOSS ASSOCIATED WITH THE EMAIL OF MY RECORDS. -------------------------------------------------------------------------------- CONFIRMATION -------------------------------------------------------------------------------- E-Signature * e.g. John Doe Submit to Prime 2023 - Prime Medical Patent Pending * * * * * 1.25.8521.41789