VALE HEARING HEALTHCARE
Occupational Audiometric Questionnaire
Please Fill In The Form Below
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Contact Number
*
Email Address
*
Confirmation Email
example@example.com
Date Of Birth
*
dd/mm/yy
Doctors Name And Address
*
Company Name
*
Occupation
*
Number Of Years At Company
*
The Following questions are completed before testing to be used only in relation to you hearing test - let the tester know if you are unsure of anything.
Have you ever had a hearing test before? If yes please state In box below.
*
Yes
No
Date Of Last Hearing Test And Where (approximately)
Have You Worked In A Previous Noisy Job? If Yes Answer Below Where And When.
*
Yes
No
Noisy Job Description And Location.
Name Any Noisy Areas That You Work In, In Your Current Job
Do You Think You May Have A Hearing Problem? If Yes Describe Below
*
Yes
No
Describe Your Hearing Problem
Do Any Family Members Have Hearing Problems Or Use Hearing Aids? If Yes Fill In Details Below.
*
Yes
No
Family Members Hearing Problems
Do You Have Any Troubling Noises In Your Head Or Ears? If Yes Fill In Details Below
*
Yes
No
Troubling Noises Details
Have You Ever Had Ear Trouble Such As Wax, Ear Infections, Blockages in The Ear? If Yes Fill In Details Below.
*
Yes
No
Description Of Ear Trouble
Name Main Pastime / Any Part-Time Work That You Do
Do You Regularly Use A Motorbike, Attend Motor Racing Or Use Guns? If Yes Explain Below.
*
Yes
No
Description of Motorbike, Racing Or Guns
Do You Smoke?
*
Yes
No
Have You Had A Cold In The Last Fortnight?
Yes
No
Have You Been In Loud Noise In The Last 16 Hours? E.G. Disco, Live Bands, Working Noise Or Power Tools. If Yes State Below
*
Yes
No
Type Of Loud Noise Within 16 Hours
Tick Any Of These Illnesses etc. That You Have Had
*
Head / Neck Injury
Bacterial Meningitis
Mumps / Measles
Scarlet / Rheumatic Fever
Epilepsy
TB Treated
Kidney Infection
Ear / Nose/ Throat Specialist Appointment
None Of The Above
Are Ear Defenders / Ear Plugs Always Available In Work?
*
Yes
No
Do You Wear Ear Protection In Noise? If Yes Select Below
*
Always
Sometimes
Rarely
Type Of Ear Protection Used
Ear Plugs
Ear Caps
Ear Muffs / Headphones
Industrial Ear Defenders
Declaration
The information I have given Is complete and correct, withholding Information may interfere with the hearing assessment and make it invalid. I can ask for an explanation of my results after the test. I understand that my employer will see the classification of my audiogram but is not entitled to any of my medical information given here without my permission.
By Ticking The Box Below You Are Giving An Electronic Signature
*
By Clicking This Box Below Is An Electronic Signature And Is Legally Binding
Please verify that you are human
*
Submit
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