You are medically approved for the following types of Respirator:
Respirator Type
Half Face Respirator
Frequency of Respirator Usage
Daily
Work Load
Light to Heavy Duty work with potential lifting excess of 50lbs
Work Shift Hours
8 hours
What PPE Personal Protective Equipment will you be wearing while using a respirator?
LEVEL "A" : Fully encapsulated chemical suit protecting skin and eyes, positive pressure full face respirator using SCBA, inner and outer, gloves, chemical boots to protect from toxic chemicals or particles
What is the maximum expected temperature you will be working?
0-30 Degrees Fahrenheit
What is the estimated humidity range you will be working in your work environment?
0 - 20%
Comments:
None
Frequency of Medical Exam
Annually
Contact Employer
If you experience any changes in your health that could affect your ability to safely use a respirator, you should contact your employer immediately. Please feel free to contact us if you have any questions.
Signature
Respiratory Protection Healthcare Professional
Respiratory Protection Healthcare Professional
Henderson Pain Center
Respirator Medical Evaluation Results
Name: Juan Perez Location: 6661 Lund dr Las vegas NV 89108 Company: Everwood construction | Job Title:
Your Medical Evaluation Result:
Approved
Your medical approval to wear a respirator authorizes you to proceed to the respirator fit testing.
This approval is based on the information you provided in your medical evaluation screening questionnaire. You are medically approved for the following respirators that you listed:
Respirator Type:Half Face Respirator Frequency of usage: Daily
Work duration:
8 hours
Work Load: Light to Heavy Duty work with potential lifting excess of 50lbs
Clothing:
LEVEL "A" : Fully encapsulated chemical suit protecting skin and eyes, positive pressure full face respirator using SCBA, inner and outer, gloves, chemical boots to protect from toxic chemicals or particles
PLHCP Comments: NoneFrequency of Medical Exam : AnnuallyIf you should experience a change in weight of more than 20lbs or lose 20 lbs then your facial features may have changed, which can impact your respirator seal. A respirator fit test may be needed because the facial changes may impact your tight seal and your ability to be protected from toxic chemicals or particulates. We want you to stay safe and healthy while wearing a respirator and encourage you to be re-fit tested whenever your facial features are changing. If this happens, you should stop wearing the respirator and speak with your supervisor or your company’s safety director about these changes and whether a new fit test is necessary. If you have any questions regarding your medical approval and ability to safely wear and use your respirator please feel free to contact us.
Steven Olenchak, PA-CRespiratory Protection Healthcare ProfessionalDecember 6, 2025Henderson Pain Center of business provides evaluation of medical evaluation questionnaires on behalf of your employer and in accordance with all OSHA and HIPPA regulations. These evaluations are not meant, with regard to the candidate, to infer, construe or otherwise suggest any specific diagnosis nor is it an attempt to diagnose, cure or treat in any manner or by any means, methods, devises or instrumentalities, any disease, illness, pain, wound, fracture, infimrity, sickness, deformity, defect or abnormal physical or mental condition of any person evaluated. In the event that I do not pass evaluation, I understand that it is up to me and/or my supervisor at my employers to contact an appropriate physician or other licensed healthcare professional to further evaluate this matter and conduct a more thorough medical evaluation.Henderson Pain Center
1399 Galleria Drive Suite 203Henderson, NV 89074702-476-5552
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