Respirator Fit Test Medical Questionnaire Form
Complete this questionnaire so your respirator fit test team can review your health information and determine whether you can safely use a respirator.
Applicant and Respirator Information
Full Name
*
First Name
Last Name
Job Title
*
Department
Employer or Organization Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Respirator Type or Model (if known)
Reason Respirator Is Needed
*
Date of Fit Test or Questionnaire Completion
*
-
Month
-
Day
Year
Date
Medical Screening Questions
Do you have any breathing problems that could affect respirator use?
*
No
Yes
If yes, please describe your breathing problems
Have you ever been diagnosed with asthma, chronic obstructive pulmonary disease (COPD), or emphysema?
*
No
Asthma
COPD
Emphysema
More than one of these
Other
If yes, please provide details
Do you have chest pain or a known heart condition that may affect respirator use?
*
No
Chest pain
Heart condition
Both
Other
If yes, please explain
Have you ever had seizures, fainting, or frequent dizziness?
*
No
Seizures
Fainting
Dizziness
More than one of these
Other
If yes, please describe the condition and when it occurs
Do you have anxiety, claustrophobia, or another condition that may make wearing a respirator difficult?
*
No
Anxiety
Claustrophobia
Other condition
More than one of these
Other
If yes, please describe any concerns or limitations
Physical Tolerance and Respirator Use Details
Can you wear the respirator for the required period while doing your job?
*
Yes
No
Not sure
Do you have trouble breathing while wearing masks or tight face coverings?
*
Yes
No
Sometimes
Does facial hair or another factor interfere with the respirator seal?
*
Yes
No
Not sure
Do you wear corrective lenses or other eyewear while using a respirator?
Yes
No
If yes, please describe the eyewear used with the respirator
Acknowledgment and Submission
I confirm that the information I provided is complete and accurate, and I understand it will be used to determine respirator fit-test eligibility.
*
I agree
Additional Notes or Comments
Submit Medical Questionnaire
Submit Questionnaire
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