Veteran History Form

  • Veteran History Form

  • Where were you a service member?*
  • Did you serve in a combat zone?*
  • If Yes, in what war(s) did you serve?

  • Military Noise Exposure

    Please reflect on your hazardous noise exposure During Military Service.
  • Were you exposed to loud noise DURING MILITARY SERVICE?*
  • How often were you exposed to these loud sounds?*
  • Did you wear hearing protection consistently in military noisy settings?

  • Non-Military Noise Exposure

    Noise environments from Before entering service, and/or After service exposures:

  • Your occupation outside of military service?                  

  • Were you exposed to loud noise BEFORE OR AFTER you served in the military?*
  • How often were you exposed to these loud sounds (non-military related)?
  • Did you wear hearing protection in the Non-military noisy settings?

  • Hearing History

    Please describe your current hearing
  • How would you describe your hearing?*
  • Has your hearing changed since it began?
  • In which ear do you hear the WORST?
  • Have you ever had ear surgery?

  • 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)?*
  • Is the noise in one or both ears?
  • How often do you hear your Tinnitus?*
  • Has the noise changed since it first began?*
  • Please check all that apply:
  • Should be Empty: