Respiratory Fit Form

Respiratory Fit Form
Name *

First Name Last Name
*

RN LPN CNA
Date of Birth *

Month Day Year
Date
Home Address *

Street Address

Street Address Line 2

City 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
Should be Empty:

Respiratory Fit Form

Please answer the following questions in regards to your personal health history.