N95 Respirator Medical Evaluation Questionnaire Form
Please complete this form to help determine if you can safely use an N95 respirator. Your responses are confidential and used only for medical evaluation purposes.
Full Name
*
First Name
Last Name
Age
*
Have you ever had any of the following medical conditions? (Select all that apply)
*
Asthma
Chronic bronchitis
Emphysema
Heart disease
High blood pressure
Seizures
Diabetes
None of the above
Other
Do you currently have any of the following symptoms? (Select all that apply)
*
Shortness of breath
Chest pain
Coughing
Wheezing
Dizziness
None of the above
Have you ever had any problems wearing a respirator in the past?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
If yes, please list your current medications (or enter "N/A" if not applicable):
Do you have any allergies that may affect respirator use?
*
Yes
No
Please describe any difficulties you have experienced with breathing, or any other medical concerns relevant to respirator use:
*
Submit Evaluation
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