Hearing Questionnaire
Yes No Yes No 1. Do you have a history of hearing loss? 7. Have you ever been exposed to loud noise from? If yes, which ear(s)? Right Left Airplanes Chainsaws 2. Do you wear hearing aid(s)? Explosive devices If yes, which ear(s)? Right Left Gunfire Heavy machinery 3. Do you currently have a head cold, Military service sinus infection, or hay fever? Motorcycles Music 4. In the last 30 days, have you had? Power boats Ear infection Snowmobiles Ear pain Tractors or other farm equipment Drainage from the ear Workplace Ruptured ear drum Other source: ______ Dizziness Ringing in the ears When exposed to loud noise, how often do you Any hearing loss wear hearing protection? Always Usually Sometimes Never 5. Have you ever had? Recurrent ear infections 8. Have you ever had these health conditions? Severe ear pain Diabetes Drainage from ear Hypertension Ruptured ear drum Dizziness 9. Have you ever taken these medications? Ringing in the ears Water pill (e.g. Lasix) Ear injury High dose aspirin (more than 5 tablets per day) Head injury Tubes placed in ear 10. Have you ever received these treatments? Other ear surgery IV antibiotics Mumps Chemotherapy Meningitis Any hearing loss 11. Have you ever been in the military or reserves? If yes, which service? ______6. In the last 14 hours, have you been exposed to loud noise at work or at home? When did you serve? ______If yes, did you wear hearing protection? Yes No
To be completed by HealthPartners nursing staff: Left Ear Exam: TM Clear: No Yes Wax present: No Yes (please circle)- small – moderate - occluded Right Ear Exam: TM Clear: No Yes Wax present: No Yes (please circle)- small – moderate - occluded Type of Test: Preplacement Baseline Annual Retest Exit Other: ______Comments:______Audiogram Technician Signature______