Veteran History Form

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 NameLast Name
Are you currently active in military?
Where were you a service member?

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?
Did you serve in a combat zone?
If yes, what war did you serve in a combat zone?

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?
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?

Other
Did you wear hearing protection consistently in these settings?

Other (describe here)
Were you exposed to significant noise DURING military service?
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?

Other
Did you wear hearing protection consistently in these settings?

Other (describe here)
Were you exposed to significant noise AFTER military service?
What loud sounds were you exposed to after service?
Ex: lawnmowers, motorcycles, etc
How often are you exposed to loud sounds after military service?

Other
Did you wear hearing protection consistently in these settings?

Other (describe here)
How would you describe your hearing:

Other
Which ear do you have difficulty hearing out of?
Have you ever had ear surgery?
How long has your hearing loss been present?
Ex: since 1990, over 20 years ago, etc
Has your hearing loss changed since it began?
Do you currently experience tinnitus (noises like ringing, buzzing, humming in your ears)?
Is the tinnitus in one ear or both ears?
Is it a constant or intermittent sound?
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?

Other
If it has gotten worse - how has it changed since it started?
Check all that apply:

Other (explain here)
Should be Empty:

Veteran History Form

Noise Exposure