Music Industry Form

Confidential case history

Please complete this form to the best of your ability. Leave blank any questions that do not apply to you.
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Band/Orchestra/Institution name:
Type of work (performer engineer, etc.):
Primary work environment(s) (studio, touring, stationary, teaching, etc):
Instruments (please list), or vocalist?
How many years have you been exposed to music?
How many years has it been loud?
Is music a profession or hobby for you?
On average, how many days per week are you exposed?
On average, how many hours per day are you exposed?
Does one ear have more sound exposure? If so, which one?
Have you experienced acoustic trauma (i.e. very loud feedback)?
If yes, please explain:
On average, what percentage of time do you wear hearing protection when exposed to loud music?
How many years have you worn hearing protection?
What type of hearing protection do you wear?

Other
Please check any of the following that you experience:

Other
If you selected "other" above, please explain:
If you selected "tinnitus" above, please describe:
Do you consider your work environment to be:
Do you consider your own playing to be:
Do you wear any of the following for casual listening throughout the day?
Do you wear either (or both) of the following while working?
If you wear in-ear monitors, what brand(s) do you wear?
Do you consider in-ear monitors to be a protective device?

Please check any non-music sound exposure you have experienced:

Rows	Check if exposed	How many years?	Type of protection used?
Military service
Industrial (factory work)
Motorcycles
Tractors/farm equipment
Firearms (hunting/targets)
Other

Do you smoke tobacco?
If yes, how much and for how long?
Do you take aspirin?
If yes, how much and for how long?
Do you have caffeine intake?
If yes, how much and for how long?
Do you drink alcohol?
If yes, how much and for how long?
Please check any of the following that apply to your personal medical history:
If you selected "other," please explain:
Please draw yourself in relation to relation to your primary sound sources. (NOT REQUIRED)
Please mention anything else that you would like:
I hereby authorize Dr. Heather Malyuk to release any medical or incidental information that may be necessary for either medical care with other providers with whom I have signed a release form. (NOT REQUIRED)
Should be Empty:

Confidential case history