Please review the questions below. If you answer yes to any of these questions please call us to speak to our Fit Testing Technician prior to your appointment.

1. Have you ever worn a respirator and had difficulties using the respirator ☐ Yes ☐ No

2. Have you ever had any of the following respiratory conditions?

• Asthma/COPD: ☐ Yes ☐ No

• Pneumonia: ☐ Yes ☐ No

• Chronic Bronchitis: ☐ Yes ☐ No

• Emphysema: ☐ Yes ☐ No

If you take puffers/inhalers for asthma or any lunch condition, please bring them with you to the fit testing

3. Do you have any other lung or breathing problems?

• ☐ Yes ☐ No

4. Have you ever had any of the following conditions:

• Epilepsy/Seizure Disorder: ☐ Yes ☐ No

• Diabetes: ☐ Yes ☐ No

• History of fainting: ☐ Yes ☐ No

• Heart Problems: ☐ Yes ☐ No

• High Blood Pressure: ☐ Yes ☐ No

• Claustrophobia: ☐ Yes ☐ No

5. Have you ever had any allergic reactions that interfere with your breathing?

• ☐ Yes ☐ No

6. Do you have Latex sensitivity/allergy or any other allergies?

• ☐ Yes ☐ No

Mask Fit Test Health Questionnaire