* 1. Employee Name

* 2. Employee ID Number

* 3. Supervisor Name

* 4. Date of Birth

* 5. Work Location

* 6. Job Title

* 29. Do you have any allergies. If so - Please state what they are

* 31. Were you exposed to loud noise prior to this hearing test? If so, how long? Did you wear protection?

* 33. Have you served in the military? If so, how many years?

* 34. Do you have noisy hobbies? Please list...

* 36. Do you shoot firearms/guns? If so, for how long? Which hand do you use to pull the trigger?

* 38. Do you take prescription medication? Please list...

* 39. Do you take aspirin? How much and how often?

* 40. Do you use chainsaws? Please list % Personal and Work use

* 41. Do you use power lawn equipment? Please list % of Personal and Work use

* 42. Do you use farm equipment? Please list % of Personal and Work use

* 43. Do you use power tools? Please list % of Personal and Work use.

* 44. Do you ride motorcycles? Do you wear hearing protection? 

* 45. Do you ride power boats? Do you wear hearing protection?

* 46. Do you ride snowmobiles? Do you wear hearing protection?

* 47. Do you ride ATV's? Do you wear hearing protection?

* 48. Do you play in a band? Do you wear hearing protection?

* 49. Are you a spectator to other loud activities (Concerts, Auto racing, etc)? Please list

* 50. Please list any other activities that could be considered loud that you are involved in. Please document how many years you have been involved...

* 51. Employee Signature - By typing your name you attest that the information provided on this questionnaire is true and accurate to the best of your knowledge

* 52. Date

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