Confidential Hearing History Questionnaire Parent Company(Required)Division(Required)Date(Required) MM slash DD slash YYYY Name(Required)Birthdate(Required) MM slash DD slash YYYY Employee ID #(Required)Is this your 1st test with this company?(Required) Yes No Did you wear Hearing Protection prior to this test?(Required) Yes No Do you regularly wear hearing protection at work?(Required) Yes No Please check one:(Required) PLUGS MUFFS BOTH Do you have problems wearing hearing protection?(Required) Yes No Current InformationHave problems with allergies or have fever?(Required) Yes No Have a head cold today?(Required) Yes No Have problems with ear wax buildup?(Required) Yes No Wear a hearing aid?(Required) Yes No HistoryHad ear surgery or injury?(Required) Yes No Had mumps, measles, or meningitis? Scarlet fever?(Required) Yes No Scarlet fever?(Required) Yes No Have you had earaches, ear infections, or drainage from ears during the past year?(Required) Yes No Had a past head injury where you lost consciousness?(Required) Yes No Do you suffer from ringing in your ears?(Required) Yes No Recently experienced dizziness?(Required) Yes No Any Military Service?(Required) Yes No Any trouble with hearing loss?(Required) Yes No Do you participate in any loud activities away from work?(Required) Yes No Any previous jobs with loud noise?(Required) Yes No SignatureBy signing this form, you are releasing your hearing test records to Onsite Medical Service Inc. and their affiliates.Name(Required)
