Woodgrange Medical Practice & London Underground Medicals
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Occupational Health Audiometry Questionnaire
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PRIVATE & CONFIDENTIAL
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Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then please complete a handwritten form when you visit the Practice.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
TO BE COMPLETED BY THE PERSON HAVING THE HEARING TEST
Name:
Date of Birth:
Employee number:
Telephone:
Home address:
QUESTIONS:
1. Have you ever worked in a noisy environment?
If yes, please give details
2. Do you have to wear hearing protection?
If yes, please give details:
3. Do you have regular hearing tests?:
If yes, please give details:
4. Do you have any problems with your hearing?:
If yes, please give details:
5. Do you suffer from wax in your ears?:
If yes, please give details:
6. Is there any deafness in your family?:
If yes, please give details:
7. Have you ever fired guns?:
If yes, please give details:
8. Have you ever been in an explosion?
If yes, please give details:
9. Have you got any problems with your balance?
If yes, please give details:
10. Do you listen to loud music via headphones?
If yes, please give details:
11. Do you ride a motorbike?
If yes, please give details:
12. Have you had any of the following diseases?
13. Is your hobby?
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DATA PROTECTION 1998
Please note this questionnaire will be sent to London Underground Occupational Health where it will be reviewed by an Occupational Health Adviser as part of your medical assessment. It will be retained by London Underground Occupational Health.
This information will only be released with your written consent. However, should you make any significant omissions or misrepresentation, such information could be disclosed to your Employing and/or Recruitment Manager at their request.
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*THIS SECTION IS TO BE COMPLETED BY THE NURSE AT THE TIME OF THE TEST*
| Last exposure to noise today (please circle as appropriate): |
Work |
Hobby |
Travelling
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| Please circle as appropriate: |
| Have you worn hearing protection in the hours before this test? |
YES / NO
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| Any ringing, whistling or other sounds in your ears when you arrived for the test? |
YES / NO
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| Is there a problem affecting your hearing today? |
YES / NO
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| Cold |
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| Ear Infection |
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| Swimming / Diving |
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| Flying |
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| Other |
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