Veteran History Form
Full Name
Please write your first and last name 9(i.e. John Doe)
What years were you in service?
*
Ex: 1990-1996
Full Name
*
First Name
Last Name
Are you currently active in military?
*
Yes
No
Reserves
Where were you a service member?
*
Navy
Marines
Army
Air Force
Coast Guard
Air National Guard
Army National Guard
Other
What was your occupation in military? (MOS, list all applicable)
*
Please state the job title(s)
Are you a right-handed or left-handed shooter?
*
Right
Left
Both
Did you serve in a combat zone?
*
Yes
No
If yes, what war did you serve in a combat zone?
WWII (1941-1946)
Korean War (1950-1955)
Vietnam War (1961-1975)
Gulf War (1990-1991)
Afghanistan War (2001-X)
Iraq War (2003-2011)
Other
Noise Exposure
Reflect on your hazardous noise history from before, during, and after military service:
Were you exposed to significant noise BEFORE military service?
*
Yes
No
If yes, what loud noises were you exposed to before military service?
Such as firearms, lawnmowers, etc
How often were you exposed to loud sounds before military service?
Seldom (less than once a month, less than 5 minutes each instance)
Occasionally (once a week to once a month, 5 minutes to an hour per instance)
Regularly (more than once a week, 1+ hour per instance)
Daily (1+ hours per day)
Other
Did you wear hearing protection consistently in these settings?
Yes
No
Other (describe here)
Were you exposed to significant noise DURING military service?
*
Yes
No
What loud sounds were you exposed to during service?
Ex: firearms, military vehicles, aircraft, etc
How often were you exposed to loud sounds during military service?
Seldom (less than once a month, less than 5 minutes each instance)
Occasionally (once a week to once a month, 5 minutes to an hour per instance)
Regularly (more than once a week, 1+ hour per instance)
Daily (1+ hours per day)
Other
Did you wear hearing protection consistently in these settings?
Yes
No
Other (describe here)
Were you exposed to significant noise AFTER military service?
*
Yes
No
What loud sounds were you exposed to after service?
Ex: lawnmowers, motorcycles, etc
How often are you exposed to loud sounds after military service?
Seldom (less than once a month, less than 5 minutes each instance)
Occasionally (once a week to once a month, 5 minutes to an hour per instance)
Regularly (more than once a week, 1+ hour per instance)
Daily (1+ hours per day)
Other
Did you wear hearing protection consistently in these settings?
Yes
No
Other (describe here)
How would you describe your hearing:
*
Hearing is fine with no concerns.
Difficult hearing in groups.
Difficult hearing one on one.
Difficult hearing in noise.
Difficult hearing from a distance.
Can hear but not clearly.
Unable to hear.
Other
Which ear do you have difficulty hearing out of?
Right Ear
Left Ear
Both Ears
Have you ever had ear surgery?
Yes
No
How long has your hearing loss been present?
Ex: since 1990, over 20 years ago, etc
Has your hearing loss changed since it began?
Stayed the same
Improved
Worsened gradually
Worsened significantly
Do you currently experience tinnitus (noises like ringing, buzzing, humming in your ears)?
*
Yes
No
Not Sure
Is the tinnitus in one ear or both ears?
Right ear
Left ear
Both
Is it a constant or intermittent sound?
Constant
Intermittent
How often do you hear the tinnitus? (Once a day, once a week, once a month, etc)
How long is the tinnitus present when it occurs? (seconds, minutes, hours, days)
What year did you first hear the noises in your ear(s)?
I.e. 2006 or 1990's
Has the tinnitus changed since it began?
Worse
Better
Stayed the same
Other
If it has gotten worse - how has it changed since it started?
Check all that apply:
*
My tinnitus is distracting and stops me from focusing.
My tinnitus stops me from sleeping or makes it difficult to fall asleep.
My tinnitus is annoying or bothersome to me.
Other (explain here)
Submit
Should be Empty: