Orange County NC Website
Revised -XO\ <br />Date: ____________________ <br />Name: ____________________ Affiliation: ____________________ <br />Birthdate: __________________ Social Security #: ______________ <br />Pre-Fit Test Evaluation: <br />Evaluator: _____________________________________________________ <br />Blood Pressure: _____________ Respirations: ___________________ <br />Pulse: _____________________ Pulse Oximitry: __________________ <br />Post-Fit Test Evaluation: <br />Evaluator: _______________________________________________________ <br />Blood Pressure: _____________ Respirations: ___________________ <br />Pulse: _____________________ Pulse Oximitry: __________________ <br />Orange County Emergency Services <br />Medical Screening <br />Pre / Post Fit Testing <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD