Respirator User Health Screening Form Page 3
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44. Respirator User Health Information
a) Some medical conditions can seriously affect your ability to safely use a respirator.
PLEASE DO NOT SPECIFY HEALTH CONDITION ON THIS FORM
Review the list below and then check either YES or NO if you experience any of the following conditions, or any
other condition that may affect your ability to use a respirator.
YES
NO
Shortness of breath
Cardiovascular disease
Allergies
Chronic bronchitis
Diabetes
Temperature susceptibility
Lung disease
Fainting spells
Claustrophobia
Heart problems
Seizures
Dentures
Hypertension
Panic attacks
Colour blindness
Thyroid problems
Fear of heights
Pacemaker
Neuromuscular disease
Hearing impairment
Unusual Facial features/skin conditions
Dizziness/nausea
Asthma
Prescription medication to control a condition
Breathing difficulties
Reduced sense of smell
Vision impairment (Not applicable to wearing
Emphysema
Reduced sense of taste
N95 & half face masks)
Chest pain on exertion
Back/neck problems
Other condition(s) affecting respirator use
b) have you had previous difficulty while using a respirator?
yes
no
never worn
c) do you have any concerns about your future ability to use a respirator safely?
yes
no
never worn
Note: If you answer “Yes” to questions “a”, “b” or “c” fit testing cannot be performed and a further assessment
by the Occupational Health Nurse is required.
Signature of respirator user:
Date:
EHS-RP-F6-R1
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Parent category: Medical