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:
Yes No Remarks
1.1 Are you currently treated by a doctor for any illness or injury? If so, please explain 1 2
Yes No Remarks
1.2Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)? If so, please explain 4 5

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

	Yes	No	Remarks
1.2Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)? If so, please explain	4	5

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

	Yes	No
2.1 High Blood Pressure	6	7
2.2 Diabetes	8	9
2.3 Kidney Disease	10	11
2.4 Cancer	12	13
2.5 Head Injury, Spinal Injury	14	15
2.6 Measles	16	17
2.7 Mumps	18	19
2.8 Meningtis	20	21
2.9 Chickenfox	22	23
2.10 Scarlet Fever	24	25
2.11 Rheumatic Fever	26	27
2.12 High Fever	28	29
2.13 Allergies	30	31
2.14 Recent sinus problem	32	33
2.15 Dizziness, vertigo, problems with balance	34	35
2.16 Tinnitus or ringing in ears	36	37
2.17 Hearing or loss or deafness	38	39
2.18 Use a hearing aid	40	41
2.19 Ear or mastoid operation	42	43
2.20 Ear infections	44	45
2.21 Drainage from ears	46	47

Do you engage in any of the following activities?

	Yes	No
3.1. Motorcycles	48	49
3.2. Power tools (chain saw, snow/leaf blower, metal grinding, lawnmower)	50	51
3.3. Loud music	52	53
3.4 Gunfire noise (hunting, shooting) / blast / explosions	54	55
3.5 Power boating	56	57
3.6 Diving	58	59
3.7 Boxing	60	61
3.9 Woodworking	62	63
3.10 Race cars / Work on running engines	64	65
3.11 Work around military equipment	66	67
3.12 Private flying	68	69
3.13 Other loud noise. Please explain	70	71

Yes No
4.0 Do you have a family history of hearing loss? (Before age 50) 73 74
Yes No
5.0 Do you have any conditions that prevent you from properly wearing hearing protectors? 76 77
Yes No
6.0 Do you use hearing protection outside of work? 79 80
Yes No
7.0 Do you use hearing protection at work? 82 83
Yes No
8.0 Are you exposed to loud hand tools at work? 85 86
Yes No
9.0 Has your noise exposure at work increased in the last year? 88 89
Yes No
10.0 Have you been exposed to noise in the last 14 hours? 91 92
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