Respiratory Fit Form
Name
*
First Name
Last Name
*
RN
LPN
RT
CNA
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Height
*
Weight
*
Respiratory In Use:
*
Have you ever worn a respirator?
*
YES
NO
Respirator Mask Size
*
SMALL
MEDIUM
LARGE
X-LARGE
Do you currently smoke, or have you smoked in the past month?
*
YES
NO
Please answer the following questions in regards to your personal health history.
Have you had or currently have the following conditions:
Seizures:
*
YES
NO
Diabetes:
*
YES
NO
Allergic Reactions:
*
YES
NO
Claustrophobia:
*
YES
NO
Trouble Smelling Odors:
*
YES
NO
Asbestosis:
*
YES
NO
Asthma:
*
YES
NO
Chronic Bronchitis:
*
YES
NO
Emphysema:
*
YES
NO
Pneumonia:
*
YES
NO
Tuberculosis:
*
YES
NO
Silicosis:
*
YES
NO
Pneumothorax:
*
YES
NO
Lung Cancer:
*
YES
NO
Broken Ribs:
*
YES
NO
Chest injury/Surgery:
*
YES
NO
Any other lung disorders:
*
YES
NO
Shortness of breath:
*
YES
NO
Shortness of breath when walking ground level or slight incline:
*
YES
NO
Shortness of breath when walking at ordinary pace:
*
YES
NO
Have to stop for a breath while walking:
*
YES
NO
Shortness of breath while washing/dressing yourself:
*
YES
NO
Shortness of breath that interferes with work:
*
YES
NO
Coughing that produces phlegm:
*
YES
NO
Coughing that wakes you up:
*
YES
NO
Coughing when lying down:
*
YES
NO
Wheezing:
*
YES
NO
Wheezing that interferes with your job:
*
YES
NO
Chest pain when you breath deeply:
*
YES
NO
Any other symptoms related to lung problems:
*
YES
NO
Heart attack:
*
YES
NO
Stroke:
*
YES
NO
Angina:
*
YES
NO
Heart failure:
*
YES
NO
Swelling in legs or feet:
*
YES
NO
Heart arrhythmia:
*
YES
NO
Hypertension:
*
YES
NO
Any other problems that you have been told about:
*
YES
NO
Frequent pain/tightness in chest:
*
YES
NO
Frequent pain/tightness in chest with physical activity:
*
YES
NO
Frequent pain/tightness in chest that interferes with your job:
*
YES
NO
Frequent pain/tightness in chest that interferes with your job:
*
YES
NO
In the past two years, have you noticed heart skipping a beat:
*
YES
NO
Heartburn or indigestion not related eating:
*
YES
NO
Any other problems related to your heart:
*
YES
NO
Breathing or lung medications:
*
YES
NO
Heart medications:
*
YES
NO
Blood pressure medications:
*
YES
NO
Seizure medications:
*
YES
NO
While wearing a respirator mask, experienced eye irritation:
*
YES
NO
While wearing a respirator mask, experienced allergies/rash:
*
YES
NO
While wearing a respirator mask, experienced anxiety:
*
YES
NO
While wearing a respirator mask, experienced weakness/fatigue:
*
YES
NO
While wearing a respirator mask, experienced any other problems that interfere with the use:
*
YES
NO
Do you need to talk to a healthcare professional in regards to this questionnaire:
*
YES
NO
Signature
*
Clear
Todays Date
-
Month
-
Day
Year
Date
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