Company Health Services Ltd Audiometry Questionnaire

Company Name. Location... .

SURNAME.... Forenames.

Sex M/F Date of Birth. Nl Number DDDD

Current employment
Job Title-- Start Date.

Noise exposure >80 dbA (noise intrusive but normal conversation possible)
Yes No
Were you exposed to noise in a previous job? D D If Yes, for how many years ?
Are you exposed to noise in your current job? D D If Yes, for how many years? .

Hearing protection
Yes No Wool Plugs Muffs Other
Did you wear hearing protection in previous employments? D D D D D D
Do you wear hearing protection in your current job? D D D D D D

Medical history
Have you or did you have: Yes No No
Yes
1] earache, discharge or other ear disease as a child? U
7] wax removed from your ears with syringing D
2] hearing loss due to any illness? Please indicate
or drops
which : Mumps LJ Measles U Meningitis LJother U
8] been given a hearing aid
3] ringing in the ears (tinnitus)?
9] Is there a family history of deafness
4] been prescribed drugs that harm hearing? LJ
If yes which one?..................................
5] had a head injury? D D
6] been exposed to impact noise, gunshot or explosion U D D
10] Do you consider your hearing to be normal? U
11] Have you had a hearing test previously? U
12] Have you ever seen an ENT surgeon?
13] Do you regularly engage in noisy pursuits eg riding
a motorcycle or attending musical events?

Otoscopic examination Yes No Yes No 2] Exudate in EAM

1] Wax in the EAM < 50% of TM visible? Lett D Right D 3] TM : Lett Normal / Scarred /
Left D D Right D D
Right Normal / Scarred / Perforated
Perforated
4] TTS effects: exposed to noise during previous 48 hours U D
5] Hearing protection worn before test Advice given :
Audiometrv U Noise information leaflet given U
kHz Left Right HSE Cateaories Instruction on hearing protection
1.0 1 Normal 2 Mild (at LJ Should wear hearing protection when working in
2.0 warning level) 3 Poor (at noisy environments
3.0 referral level) 4 Rapid U Must wear hearing protection when working in noisy
4.0 environments
(refer)
6.0 HSE Category 1 2 3 4
Total D Refer to................................................
D Other..,

Sum 3,4,6 kHz ?> 30dB in last 3 years

Sum 1,2,3,4 kHz >40dB = unilateral loss

Date of test, OHA/P CHS 4/2006