Confidential case history
Please complete this form to the best of your ability. Leave blank any questions that do not apply to you.
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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?
Please Select
1
2
3
4
5
6
7
8
9
10
On average, how many hours per day are you exposed?
Please Select
1
2
3
4
5
6
7
8
Does one ear have more sound exposure? If so, which one?
They're equally exposed
Right
Left
Have you experienced acoustic trauma (i.e. very loud feedback)?
Yes
No
If yes, please explain:
On average, what percentage of time do you wear hearing protection when exposed to loud music?
0%
25%
50%
75%
100%
How many years have you worn hearing protection?
What type of hearing protection do you wear?
Foam earplugs
Other non-custom plugs
Filtered custom earplugs
Solid custom earplugs
Earmuffs
Other
Please check any of the following that you experience:
Tinnitus (ringing/buzzing in your ear(s) lasting longer than 5 minutes at a time)
Distortion
Sensitivity to sound
Pitch perception issues
Difficulty understanding speech in background noise
Difficulty understanding speech in quiet
Other
If you selected "other" above, please explain:
If you selected "tinnitus" above, please describe:
Do you consider your work environment to be:
Too loud
Not loud enough
Just right
Do you consider your own playing to be:
Too loud
Not loud enough
Just right
Do you wear any of the following for casual listening throughout the day?
Earbuds
Earphones
Headphones
Do you wear either (or both) of the following while working?
In-ear monitors
Studio headphones
If you wear in-ear monitors, what brand(s) do you wear?
Do you consider in-ear monitors to be a protective device?
Yes
No
Please check any non-music sound exposure you have experienced:
Check if exposed
How many years?
Type of protection used?
Military service
None
Non-custom earplugs
Custom earplugs
Earmuffs
Industrial (factory work)
None
Non-custom earplugs
Custom earplugs
Earmuffs
Motorcycles
None
Non-custom earplugs
Custom earplugs
Earmuffs
Tractors/farm equipment
None
Non-custom earplugs
Custom earplugs
Earmuffs
Firearms (hunting/targets)
None
Non-custom earplugs
Custom earplugs
Earmuffs
Other
None
Non-custom earplugs
Custom earplugs
Earmuffs
Do you smoke tobacco?
Yes
No
If yes, how much and for how long?
Do you take aspirin?
Yes
No
If yes, how much and for how long?
Do you have caffeine intake?
Yes
No
If yes, how much and for how long?
Do you drink alcohol?
Yes
No
If yes, how much and for how long?
Please check any of the following that apply to your personal medical history:
Ear infection
Ear surgery
Use of life-saving medications
Dizziness/vertigo
Heart disease
Kidney disease
Sudden hearing loss
Fluctuating hearing loss
Family history of hearing loss
Other
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)
Submit
Should be Empty: