Centre for Occupational Health

Stockport

NHS

Tel: 0161-419 -5491

Fax: 0161-419-4953

NHS FoundationTrust

HEARING ASSESSMENT QUESTIONNAIRE

INITIAL/REVIEW (Please delete)

Name: ...... Date: ......

Date of birth: ......

Employer:…………………….Work Area:…………………

(1)Have you ever worked in a noisy environment or with noisy tools? YES/NO

If YES, please complete the following:

a)Employer/Company ______

b)Occupation ______

c)Years of service (please give dates) ______

d) Did you wear ear protection? (i) always (ii) occasionally (iii) never

e)Type of protection worn ______

2Do you have any difficulty with your hearing?Yes/No

If yes.....

How long have you had this trouble? ______

Which ear is affected? Left/Right/Both

Was the deafness sudden/gradual? ______

Is the deafness getting worse/better/not changing? ______

3.Do you have a hearing aid?Yes/No

4.Is there a family history of hearing loss ?Yes/No

Details ______

5.Do you have noises in your ears?

Always/Occasionally/Sometimes/Never

What are these noises like? ______

How long do they last? ______

6.Have you suffered from any of the following? (Please give details)

a)an injury to your ear(s)Yes/No ______

b)an operation on your ear(s)Yes/No ______

c)a recurrent ear infectionYes/No ______

d)a perforated ear drumYes/No ______

e)a discharge from your ear(s)Yes/No ______

f)pains in your ear(s)Yes/No ______

g)Dizziness/giddinessYes/No ______

h)Temporary deafnessYes/No______

7.Have you ever had an injury to the head which made you unconscious Yes/No

If yes, please give details ______

8.Have you ever had any of the following? (Please give details)

a)MeningitisYes/No ______

b)TuberculosisYes/No ______

c)MeaslesYes/No ______

d)MumpsYes/No ______

e)Chicken poxYes/No ______

f)Scarlet feverYes/No ______

g)RubellaYes/No ______

h)MalariaYes/No ______

i)Rheumatic feverYes/No ______

9.Have you ever worked in the armed forces or Territorial Army?Yes/No

Details ______

10.Have you ever been exposed to a blast/explosion/gunfire?Yes/No

Details ______

11.Do you have or have you ever had any of the following hobbies?

a)ShootingYes/No

b)Motor sportYes/No

c)Playing in a brass band/orchestra/pop groupYes/No

d)Going to discos/pop concerts frequentlyYes/No

12.Do you listen to music using headphones or personal stereo?Yes/No

If yes, how many hours per day? ______

13.At work in the designated areas, do you wear hearing protection?

All the time/Most of the time/Half the time/Occasionally/Never

14.What type of hearing protection do you wear? ______

15.Have you been anywhere today where you had to shout to make yourself heard?

Yes/No

Have you worn hearing protection in the hour before the test?Yes/No

Did you have ringing/whistling or other sounds in your ears when you arrived for the test? Yes/No

16.Are you taking any medication at the moment?Yes/No

Details: ______

Date: ...... Employee signature: ......