Hearing Evaluation Questionnaire

Hearing Evaluation Questionnaire
Name
First NameLast Name
IC No. or Passport No.
Company ID or Service No.
(if applicable)
Job Title
(if applicable)
Age
Please write your current age
Date Of Birth
DayMonthYear
Please answer the following:
Rows Yes No Remarks
1.1 Are you currently treated by a doctor for any illness or injury? If so, please explain 1 2
Rows Yes No Remarks
1.2Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)? If so, please explain 3 4

Rows	Yes	No	Remarks
1.1 Are you currently treated by a doctor for any illness or injury? If so, please explain	1	2

Rows	Yes	No	Remarks
1.2Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)? If so, please explain	3	4

Have you ever had, or been told by a doctor that you had any of the following?

Rows	Yes	No
2.1 High Blood Pressure	5	6
2.2 Diabetes	7	8
2.3 Kidney Disease	9	10
2.4 Cancer	11	12
2.5 Head Injury, Spinal Injury	13	14
2.6 Measles	15	16
2.7 Mumps	17	18
2.8 Meningtis	19	20
2.9 Chickenfox	21	22
2.10 Scarlet Fever	23	24
2.11 Rheumatic Fever	25	26
2.12 High Fever	27	28
2.13 Allergies	29	30
2.14 Recent sinus problem	31	32
2.15 Dizziness, vertigo, problems with balance	33	34
2.16 Tinnitus or ringing in ears	35	36
2.17 Hearing or loss or deafness	37	38
2.18 Use a hearing aid	39	40
2.19 Ear or mastoid operation	41	42
2.20 Ear infections	43	44
2.21 Drainage from ears	45	46

Do you engage in any of the following activities?

Rows	Yes	No
3.1. Motorcycles	47	48
3.2. Power tools (chain saw, snow/leaf blower, metal grinding, lawnmower)	49	50
3.3. Loud music	51	52
3.4 Gunfire noise (hunting, shooting) / blast / explosions	53	54
3.5 Power boating	55	56
3.6 Diving	57	58
3.7 Boxing	59	60
3.9 Woodworking	61	62
3.10 Race cars / Work on running engines	63	64
3.11 Work around military equipment	65	66
3.12 Private flying	67	68
3.13 Other loud noise. Please explain	69	70

Rows Yes No
4.0 Do you have a family history of hearing loss? (Before age 50) 71 72
Rows Yes No
5.0 Do you have any conditions that prevent you from properly wearing hearing protectors? 73 74
Rows Yes No
6.0 Do you use hearing protection outside of work? 75 76
Rows Yes No
7.0 Do you use hearing protection at work? 77 78
Rows Yes No
8.0 Are you exposed to loud hand tools at work? 79 80
Rows Yes No
9.0 Has your noise exposure at work increased in the last year? 81 82
Rows Yes No
10.0 Have you been exposed to noise in the last 14 hours? 83 84
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Rows	Yes	No
4.0 Do you have a family history of hearing loss? (Before age 50)	71	72

Rows	Yes	No
5.0 Do you have any conditions that prevent you from properly wearing hearing protectors?	73	74

Rows	Yes	No
6.0 Do you use hearing protection outside of work?	75	76

Rows	Yes	No
7.0 Do you use hearing protection at work?	77	78

Rows	Yes	No
8.0 Are you exposed to loud hand tools at work?	79	80

Rows	Yes	No
9.0 Has your noise exposure at work increased in the last year?	81	82

Rows	Yes	No
10.0 Have you been exposed to noise in the last 14 hours?	83	84

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