3M Ear Plug Intake Questionnaire

3M Ear Plug Intake Questionnaire
Potential clients (injured person) name:

First NameLast Name
Date Of Birth:

MonthDayYear
Date
Inquirer Name (if different):

First NameLast Name
Inquirer’s relationship to injured person:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:

Area CodePhone Number
Secondary Phone Number:

Area CodePhone Number
Email:
example@example.com
Injured Person spouse name:

First NameLast Name
If Injured Person Is Deceased...
Date of Death:

MonthDayYear
Date
State of Death
Cause(s) of Death:
Residency at time of Death: City & State:
YesNo
If yes, who has been appointed Personal Representative:
YesNo
YesNo
YesNo
YesNo
If yes when were you diagnosed with hearing loss?

MonthDayYear
Date
If yes where were you diagnosed with hearing loss (Include facility &state)
When were you diagnosed with tinnitus?

MonthDayYear
Date
Where were you diagnosed (include facility and state):
What was your home of record during your military service? (This information will be on your DD214):
YesNo
If yes, when?

MonthDayYear
Date
What state was your original home of record?
What state did you change your home of record to?
FIRST, let’s first talk about any time you may have served in the RESERVES:
YesNo
Army, Navy, Marines, Air Force, and/or Coast GuardNational GuardOther
What periods of time did you serve in the RESERVES?
For use for those individuals that signed up for the reserves a second time:
While serving in the RESERVES were you ever called up to ACTIVE DUTY? (First Time):
While serving in the RESERVES were you ever called up to ACTIVE DUTY? (Second Time):
While serving in the RESERVES were you ever called up to ACTIVE DUTY? (Third Time):
NOW, let’s talk about any time you may have served on active duty, NOT associated with the reserves:
YesNo
ArmyNavyMarinesAir ForceCoast Guard
What periods of time did you serve in ACTIVE DUTY, not associated with the reserves?
What was your discharge date from active duty – regular military?

MonthDayYear
Date
Date from ACTIVE DUTY MILITARY:

MonthDayYear
Date
In what US states and territories did you use these ear plugs?
If possible please also provide the names of the bases/facilities where used:
YesNo
When did you first become aware that your hearing loss may be related to a faulty ear plug?
Should be Empty: