HORIZON HEALTH ACCESS, PC
6 Pompton Avenue Suite 11
Cedar Grove, New Jersey 07009-2042
PH: 973-571-9180  ***  FAX: 973-571-9174

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Pulmonary Function / Respirator Fit Test

Today's Date:
Company:
Full Name:
Social Security Number:
Date of Birth:  
Street Address:  
City:
State:
Zip:
Phone Number:
Height / Weight: Feet Inches  - Weight Pounds
Smoking Information: YES I SMOKE CURRENTLY

If YES above then below enter how many Cigarettes smoked
Ex: 20 Cigarettes Per Day For 15 Years

Cigarettes Per Day For Years 

FORMER SMOKER

If yes to FORMER SMOKER above then below enter how many years ago you quit along with the number you smoked
Ex: I quit 6 Years Ago After Smoking 10 Cigarettes Per Day For 12 Years

I Quit Smoking Years Ago After Smoking Cigarettes Per Day For Years 

NO, I'VE NEVER SMOKED 

1.   

To be completed at the time of testing:

Respirator Make:
Model: Size:

 

If you'd like to start over you can hit the "reset" button to clear the form. 

 

PLEASE SIGN BELOW:

 

X                                                                                            

 

Please diligently recheck your answers before signing.

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