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:	TODAY'S DATE: Month January February March Aprill May June July August September October November December TODAY'S DATE: DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 TODAY'S DATE: Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
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Date of Birth:	DOB: MONTH January February March Aprill May June July August September October November December   DOB: DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DOB: YEAR 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
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Height / Weight:	0 1 2 3 4 5 6 7 8 Feet 0 1 2 3 4 5 6 7 8 9 10 11 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. Thank you for your time! HorizonHealthAccess.com   2011 © Horizon Health Access P.C.