Hearing Questionnaire

First Name *
Family Name *
Gender
Photo Upload
Nationality
Date of Birth
Address
Email
Mobile
Landline
Position applied for

Former Occupation(s) Please provide some detail concerning previous jobs in which you have worked.
Date	BRIEF JOB DESCRIPTION	INDICATE WHETHER ANY EXPOSURE TO CHEMICALS, DUST OR NOISE

Please answer yes or no to the following questions. If yes please give details.	Yes	No
1. Do you have a problem/difficulty with your hearing?
1a. If yes indicate right and/or left ear	Left Right Both
1b. Indicate sudden or gradual onset	Sudden Gradual
1c. Indicate if getting worse, better or no change	Worse Better No change
Have you ever had any of the following?	Yes	No	Additional Information
2. Ear injury
3. Ear operation
4. Frequent ear infections
5. Perforated ear drums
6. Ear discharge
7. Impacted wisdom teeth
8. Hearing test
	Yes	No
9. Have you seen a GP or Specialist about your ears?
10. Is there any deafness in your family?
11. Have you ever had a serious head injury or been knocked unconscious?
12. Were you hospitalised?
13. Did you have surgery?
14. Date of Injury?
Have you ever had any of the following?	Yes	No	Additional Information
15. Meningitis or Encephalitis
16. TB
17. Sinusitis
18. High Blood Pressure
19. Measles
20. Tinnitus (constant noise in ears)
21. Vertigo
22. Difficulty with smell
23. Rhinitis
24. Nasal Polyps
25. Hay fever
26. Voice disturbance, hoarseness etc.
	Yes	No
27. Have you ever taken medication that affected your hearing e.g. antibiotic, chemotherapy
28. Are you taking medication at present?
Do you have any of the following interests?	Yes	No
29. Shooting/Hunting
30. DIY using power tools etc
31. Car/Motorcycle maintenance
32. Loud music – disc, i pod, MP3 player etc.
Do you have any of the following interests?	Yes	No
33. Have you attended a disco or concert in the past 24-48 hours?
34. Have you been a member of the regular or reserve defence forces?
35. Have you ever been near an explosion?
36. Have you worked in a noisy industry or workplace in the past?
36a. If yes were you provided with hearing protection?
37. Do you smoke or have you recently quit?			If yes please indicate quantity:

Please list the work areas that you consider noisy in your present job.

Work Area	Hours per day/week	Tools/machinery	Hearing protection

Additional Information

Declaration:

I understand that the purpose of this hearing questionnaire is to confirm that

I am fit for the position I have applied for or currently working.
I can perform my duties safely and without risk to the health and safety of others.
I can render reliable and productive service for my employer

I declare that the information I have given is true and accurate to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy or otherwise of the answers above. I understand that if I have knowingly withheld material facts this may affect my appointment or continued employment.

Tick box to indicate that you understand and agree with the declaration.