Hearing Screen

Date:

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First Name:
Last Name:
Phone:
Birthdate:
Social Security#:
Current Employer:
Job Title:
Reason for Test
Baseline
Annual
Restest
Termination
Has it been more than 14 hours since your last noise exposure?
Do you Have:
Ringing in your ears
Problems with dizziness/unsteadiness
Any ear or hearing problems now
Noisy hobbies
Have you ever had:
Medical treatment for an ear problem
Sudden hearing loss
A noisy job with another company
Have you ever:
Used firearms
Served in the Armed Forces
Types of hearing protection used in the past:
Comments:
Ear Inspection (Check if True)
L                R
Eardrum Visible
Perforation
Drainage
Excess ear wax
Audiometer
Make:
Model:
Serial #:
Calib. Date:
Test Date:
Time:
Technician Cert. #
Left Ear
500
1000
2000
3000
4000
6000
8000
Right Ear
500
1000
2000
3000
4000
6000
8000