Download Hearing Questionnaire - University of Strathclyde

Occupational Health Service - Confidential
HEARING QUESTIONNAIRE
PERSONAL DETAILS
Name .………………………………………………………………. Date of Birth ……………………………………………
Location .……………………………………………………………. Job Title .……………………………………………….
MEDICAL HISTORY
1.
2.
Do you consider your hearing to be:
Left ear
Good/Fair/Poor
Right ear
Good/Fair/Poor
Do you consider your hearing to be normal
Yes
□ No□
If ‘No’, which ear? Left/Right/Both
□ No□
Yes □ No□
3.
If ‘No’, have you consulted your GP?
4.
If ‘No’, have you consulted a specialist?
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?
8.
Do you use cotton buds to clean your ears?
9.
Have you suffered any injury/trauma to your ears?
If so describe ……………………………………………………………………………………………………………..
Yes
□ No□
Yes □ No□
Yes □ No□
Yes
□
□
□
□
□
□
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 ……………………………………………………………………………………………………………..
□ No□
Yes □ No□
Yes □ No□
13. Do you suffer ringing in the ear/head?
Yes
14. Do you suffer from dizziness/giddiness?
15. Exposure to ototoxic drugs or solvents?
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 □
Yes □ No□
20. Have you had wax removed from your ears?
If Yes, when? ……………………………………………………………………………………………………………….
The University of Strathclyde is a charitable body, registered in Scotland, with registration number SC015263
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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 ………………………………………………………………………………………………………………………...
Yes
□ No□ Drum fully visible / partially visible / not seen
Yes
□ No□
Any abnormalities of the external meatus?
Yes
□ No□
Is the tympanic membrane?
Left
Normal / scarred / perforated / not seen
Right:
Normal / scarred / perforated / not seen
Is there wax in the external meatus? Left:
Right:
Any abnormalities of the tympanic membrane? Yes
Drum fully visible / partially visible / not seen
□ 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
D:\840962447.doc