Adult Audiometry - Exemed Online

Employee Details

Full Name (required)

DOB (required)//

Job Title (required)

Employer (required)

Address (required)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (required)

1. Do you have any difficulties with your hearing? (required)

Yes
No

i) How long have you had this difficulty?

ii) Which ear is affected?

Left
Right
Both

iii) Was the onset of deafness

Gradual
Sudden

iv) Is the deafness

Worse
Better
Same

v) Do you have difficulty in deciding where the noise is coming from?

Yes
No

vi) Do you have difficulty hearing conversation in crowded rooms?

Yes
No

vii) Do you have difficulty hearing female voices specifically?

Yes
No

viii) What do you put your deafness down to?

2. Do you have trouble hearing in any of these situations?

On the telephone (required)

Always
Sometimes
Never

With background noise (required)

Always
Sometimes
Never

Watching television (required)

Always
Sometimes
Never

Children talking (required)

Always
Sometimes
Never

Adults talking (required)

Always
Sometimes
Never

In movies (required)

Always
Sometimes
Never

At concerts (required)

Always
Sometimes
Never

3. Have you consulted your GP/Specialist about your hearing? (required)

Yes
No

i) When?

ii) What was the reason?

iii) Which ear(s)

Left
Right
Both

4. Have you ever had a hearing test? (required)

Yes
No

i) When?

Has a hearing aid been prescribed? (required)

Yes
No

5. Have you ever had pain in your ears? (required)

Yes
No

i) When?

ii) Which ear(s)?

Left
Right
Both

6. Have you ever had an injury to your ears? (required)

Yes
No

i) When?

ii) What was the injury?

iii) Which ear(s)?

Left
Right
Both

7. Have you ever had an operation on the ear or mastoid? (required)

Yes
No

i) When?

ii) Which ears?

Left
Right
Both

8. Has your eardrum ever punctured or ruptured? (required)

Yes
No

i) When?

ii) How caused?

iii) Which ear(s)?

Left
Right
Both

9. Have you ever had a head injury which made you unconscious? (required)

Yes
No

i) When?

ii) Which part of the head?

iii) If the ear was affected, which one?

Left
Right
Both
None

10. Do you hear noises in your ears? (required)

Yes
No

i) Which ear is affected?

Left
Right
Both

ii) Describe the noise

iii) When did you start hearing the noises?

11. Do you or have you suffered from:

a) Giddiness (required)

Yes
No

b) Discharge from the ear (required)

Yes
No

12. Have you ever had injections of Streptomycin? (required)

Yes
No

13. Have you to your knowledge ever had drugs for; Malaria/Kidney trouble/Urine problems/TB/Rheumatism? (required)

Yes
No

i) Please specify

14. Do you now take any medication? (required)

Yes
No

i) Please specify

15. Have you ever had any of the following illnesses? (required)

16. Is there any deafness in the family? (required)

Yes
No

i) Who?

ii) Deafness began at what age?

17. In your job do you have to shout to make yourself heard? (required)

Yes
No

18. Prior to your present job, have you worked in a noisy occupation where you or others had to shout to make yourselves heard? (required)

Yes
No

Please provide details of the job, how long you worked there and any hearing protection used.

19. Have you ever been regularly near or used:

Firearms (required)

Yes
No

Artillery weapons (required)

Yes
No

Explosive devices (required)

Yes
No

20. Is or has your hobby ever been:

(please tick relevant boxes)

21. Do you suffer from wax in either ear? (required)

Yes
No

Declaration

I declare that the answers given in this form are true to the best of my knowledge and belief. I consent to information regarding my hearing being passed to my employer. I consent to ExeMed processing and holding this information under the Data Protection Legislation.

Date

Adult Audiometry Questionnaire