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

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?
On average, how many hours per day are you exposed?
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
Industrial (factory work)
Motorcycles
Tractors/farm equipment
Firearms (hunting/targets)
Other

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)
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Confidential case history