Essay On Respirator Mask Fitting

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Page 1 of 2 FOR OFFICE USE ONLY – DO NOT FILL IN 3M 8210/1860 3M 8110S/1860S 3M 9210/1870 PORTACOUNT KC PFR95 – 62126 (Reg) KC PFR95 – 62355 (Sml) OTHER _____________________ N95 RESPIRATOR HEALTH QUESTIONNAIRE THIS FORM IS CONFIDENTIAL ONCE COMPLETED Mask Fitting will be completed in room 258B; Health Studies Lab Last Name: Student #: Program NAME: First name: Telephone #: Current Semester: (please circle) 1 2 3 4 5 6 7 8 PLEASE READ CAREFULLY AND COMPLETE BOTH PAGES ANY OMISSIONS OR NON-COMPLIANCE WILL RESULT IN YOU HAVING TO REBOOK AN APPOINTMENT AT YOUR EXPENSE Some symptoms/conditions can affect your ability to be safely tested and use a respirator mask If you select ‘YES’ to ANY questions on page 2, please see Kim Johnson (ext…show more content…
COPD/Asthma /Bronchitis/Emphysema ____ Yes No Yes No Persistent cough Yes No Other causes of shortness of breath If yes; please specify known cause(s) ______________________________________________________ Any food or drug or material (example: Latex) allergies Yes No If yes; please specify known cause(s) ______________________________________________ Do you or have you recently (within 1 yr) had any of the following conditions? Feelings of Claustrophobia (fear of close, tight spaces) Yes No Epilepsy / Seizure Disorder Yes No If yes; please specify known cause(s) _____________________________________________ History of fainting / syncope Yes No If yes; please specify known cause(s) _______________________________________________________ Heart condition Yes No If yes; please specify _______________________________________________________ High blood pressure Yes Yes No No Are you

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