Veteran History Form
Full Name
*
First Name
Last Name
Where were you a service member?
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Air Force
Army
Coast Guard
Marines
Navy
Other
What years were you in the service?
*
Ex: 1994 - 1997, 1999 - 2004
What was your military occupational specialty? (List all applicable)
*
Please state the military job title(s)
Did you serve in a combat zone?
*
Yes
No
If Yes, in what war(s) did you serve?
WWII (1941-1946)
Korean War (1950-1955)
Vietnam War (1961-1975)
Gulf War (1990-1991)
Afghanistan War (2001-X)
Iraq War (2003-2011)
Other
Military Noise Exposure
Please reflect on your hazardous noise exposure During Military Service.
Were you exposed to loud noise DURING MILITARY SERVICE?
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Yes
No
If yes, what type of noise were you exposed to DURING military service? Ex: aircraft, firearms, heavy equipment, artillery, military vehicles, etc. Provide details:
*
Describe the exposure (such as firearms, helicopters, engines)
How often were you exposed to these loud sounds?
*
Seldom (less than once a month, less than 5 minutes at a time)
Occasionally (less than once a week, less than an hour at a time)
Regularly (more than once a week, more than an hour at a time)
Daily (more than an hour per day)
Did you wear hearing protection consistently in military noisy settings?
Yes
No
Other
Non-Military Noise Exposure
Noise environments from Before entering service, and/or After service exposures:
Your occupation
outside
of military service?
Type a label
Were you exposed to loud noise BEFORE OR AFTER you served in the military?
*
Yes
No
What type of noise? List all: Ex: Occupational= farm equipment, machinery, trucks, refinery, etc. Recreational= concerts, motorcycles, firearms, power tools, etc. Provide all details:
Describe the exposure (such as concerts and firearms)
How often were you exposed to these loud sounds (non-military related)?
Seldom (less than once a month, less than 5 minutes at a time)
Occasionally (less than once a week, less than an hour at a time)
Regularly (more than once a week, more than an hour at a time)
Daily (more than an hour per day)
Did you wear hearing protection in the Non-military noisy settings?
Yes
No
Other
Hearing History
Please describe your current hearing
How would you describe your hearing?
*
My hearing is fine with no concerns.
I have difficulty hearing in noisy settings.
I have difficulty hearing from a distance.
I have difficulty hearing in small groups.
I have difficulty hearing one on one.
I hear speech, but cannot understand clearly.
Other
When did you notice hearing difficulty?
*
Ex: 1990 or around 40 years ago
Has your hearing changed since it began?
Worse (more difficulty hearing)
Stayed the same
Better (hearing has improved)
In which ear do you hear the WORST?
Right ear
Left ear
Both ears
Have you ever had ear surgery?
Yes
No
Which ear?
Tinnitus
Fill this form out if you currently experience any noises (buzzing, humming, ringing, clicking, roaring, etc) in your ear(s) either occasionally or constantly.
Do you currently experience noises in your ear(s)?
*
Yes
No
Unsure
What year did you first hear ear noises?
*
If you don't remember, give a general year
Please describe any noise you experience.
Ringing, Buzzing, Humming, Crickets, etc.
Is the noise in one or both ears?
Right ear
Left ear
Both ears
How often do you hear your Tinnitus?
*
Constant
Recurrent, it starts/stops often, but daily
Occasionally, 1-2 times a week
Random, for only seconds
Other
Has the noise changed since it first began?
*
Worse (louder or more frequent)
Better (less noticeable or less frequent)
Stayed the same
Other
Please 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 bothersome and annoying.
My tinnitus makes it difficulty to hear others.
It does not bother me at all.
Other
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