Occupational Health Service - Confidential

HEARING QUESTIONNAIRE

PERSONAL DETAILS

Name .………………………………………………………………. Date of Birth ……………………………………………

Location .……………………………………………………………. Job Title .……………………………………………….

MEDICAL HISTORY
1. Do you consider your hearing to be: Left ear Good/Fair/Poor
Right ear Good/Fair/Poor
2. Do you consider your hearing to be normal Yes □ No□
If ‘No’, which ear? Left/Right/Both
3. If ‘No’, have you consulted your GP? Yes □ No□
4. If ‘No’, have you consulted a specialist? Yes □ No□
5. If ‘No’, did your hearing loss come on gradually or suddenly? ………………………………………………………
6. If ‘No, is your hearing loss getting – worse/better/same? ……………………………………………………………
7. Do you wear a hearing aid? Yes □ No□
8. Do you use cotton buds to clean your ears? Yes □ No□
9. Have you suffered any injury/trauma to your ears? Yes □ No□
If so describe ……………………………………………………………………………………………………………..
10. Earache, discharge from ears or other ear disease as child or adult? Yes □ No□
Detail ……………………………………………………………………………………………………………………...
11. Any ear disease or deafness in the family? Yes □ No□
Detail ……………………………………………………………………………………………………………………….
Which relative? …………………………………………………………………………………………………………….
12. Ever suffered head injury/concussion/unconsciousness? Yes □ No□
If so describe ……………………………………………………………………………………………………………..
13. Do you suffer ringing in the ear/head? Yes □ No□
14. Do you suffer from dizziness/giddiness? Yes □ No□
15. Exposure to ototoxic drugs or solvents? Yes □ No□
Eg streptomycin, otosporin, quinine, toluene
16. Have you had any of the following illnesses? Mumps/Measles/Meningitis/Scarlet Fever/ Yes □ No□
Chicken Pox/Malaria/Ear Infection/Mastoid/Meniere’s Disease/ Operation on ear or other
Which? ……………………………………………………………………………………………………………………..
17. Exposure to gunfire/blasts/explosions? Yes □ No□
If so describe ……………………………………………………………………………………………………………...
18. Do you have any noisy hobbies? Yes □ No□
Tick all that apply: Motor Sports Ride a Motorcycle
DIY Discos/loud Music
Shooting
Other …………………………………………………………………………………………….
19. Do you hear better or worse in noise: Better □ Worse □
20. Have you had wax removed from your ears? Yes □ No□
If Yes, when? ……………………………………………………………………………………………………………….
PREVIOUS NOISE EXPOSURE
Job / Employer / Ear Protection Provided
DECLARATION

I declare that the responses I have given on this form are true to the best of my knowledge and belief.

Signature: ……………………………………………………………………. Date: …………………………………………

I agree/ do not agree to a copy of my hearing test being sent to my General Practitioner

Signature…………………………………………………………………….. Date…………………………………………..

TO BE COMPLETED BY OCCUPATIONAL HEALTH STAFF

When were you last exposed to noise: ………………………………………………………………………………………...

Noise exposure on day of test: …………………………………………………………………………………………………

Ear protection worn on day of test: No □ Yes □ Plugs / Muffs

Comments ………………………………………………………………………………………………………………………...

Is there wax in the external meatus? Left: Yes □ No□ Drum fully visible / partially visible / not seen

Right: Yes □ No□ Drum fully visible / partially visible / not seen

Any abnormalities of the external meatus? Yes □ No□

Is the tympanic membrane? Left Normal / scarred / perforated / not seen

Right: Normal / scarred / perforated / not seen

Any abnormalities of the tympanic membrane? Yes □ No□

Nurse signature …………………………………...…………………………………………. Date …… / …… / ………….

Processed in accordance with the Data Protection Act 1998

The University of Strathclyde is a charitable body, registered in Scotland, with registration number SC015263

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