Download Occupational Health Services/Oswego Hospital 140 West 6th Street

Occupational Health Services/Oswego Hospital
140 West 6th Street, Oswego, NY 13126
Name
SS#
Birth Date
Audiometric Health History
Date
Company
Job Classification
NOISE HISTORY
MEDICAL HISTORY
Have you ever been exposed
to loud noise:
In military service? Y/N
# of years _________
In previous jobs Y/N
#of years _________
Are you exposed to loud noise at a
second job? Y/N
Indicate years of exposure
to:
Fire arms ________________
Loud music______________
Power tools______________
Chain saw _______________
Motorcycles _____________
Snowmobiles _____________
Heavy machinery __________
Tractor _________________
Other __________________
Do you wear ear protection
for off-the-job noise
exposure? Y/N
Have you ever had:
Serious head injury/ knocked
unconscious? Y/N
When ___________________
Ear injury? Y/N Which ear? R/L
Cause ____________________
Ruptured eardrum? Y/N
When _________ Which ear? R/L
Cause ____________________
Ear surgery? Y/N
When ________ Which ear? R/L
What type? _________________
Serious ear infection? Y/ N
When _________ Which ear? R/L
Treated? Y/N
Do you have a known hearing loss?
Y/N
Do you wear a hearing aid? Y/N
How long? ________Which ear? R/L
Ever been seen by a doctor for ear
problems? Y/N
Explain _____________________
Are you exposed to loud noise on your present job? Y/N
Do you wear hearing protectors? Y/N Type_______
When was your last audiogram? _________________
Employee Signature____________________________________________
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Test
Date
Within the last 12 months,
Have you had any of the
following:
Ear drainage? Y/N
Continuous or recurrent ear pain? Y/N
Severe and/or constant ringing in
ears? Y/N
Unexplained dizziness? Y/N
Hearing loss that suddenly comes and
goes? Y/N
Feeling of pressure/ fullness in ears for no
apparent reason? Y/N
Do you have any allergies? Y/N
Have you seen a physician for any of the
above? Y/N
Have you been exposed to loud noise during the last 14
hours? Y/N Hours since last exposure ________
Did you use hearing protection today prior to this test?
Y/N
Do you have a head cold/sinus condition today? Y/N
Audiometric Test Results
Normal Hearing
No significant change since baseline - no follow-up needed
OSHA Standard Threshold Shift – retest in 30 days
Follow-up evaluation with audiologist recommended
Comments
Test
Type
Left Ear
.5K
Otoscopic Results
Left
Right
OK
Wax
Other
1K
2K
3K
Right Ear
4K
6K
8K
.5K
1K
2K
3K
4K
Model of Audiometer
Earscan 3 #0103030001DC
Tech signature _______________________________________________
6K
8K