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??ࡱ?>?? ]_????\??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????c? ???bjbj?Ԛ? 4^??Z\??Z\??????????JJJJJ????^^^^?d^ ?vvvvvQk w???????$"??$P?!JQQ?JJvv??\\\"JvJv?\?\\\v????p۬9?????(?\|?0 \&?\&\&J\ ?\? ?Y??V ????????????????????????????????????????????????????????????????????&?> : PLEASE PRINT AUDIOMETRIC HISTORY Adventist Health Name (Last, First, Middle Initial) Employee NumberBirth Date Date of Hire Gender ( M ( F Company LocationDeptJobShift Today NOTE: Mark Yes or No box like this ( Are you having an allergy problem today?................................................. ( No ( Yes Do you have a head cold today?............................................................... ( No ( Yes Have you been exposed to any loud noise in the past 14 hours?............ ( No ( Yes (IF YES PLEASE CONTINUE BELOW) Did you wear hearing protectors during the exposure?............ ( No ( Yes How long were you exposed to the noise?............................... Hours: ______ Level: _______ dB ( check here if unknown Where were you during the exposure?...................................... ( At work ( Away from work Within the past year Mark if you have experienced any of these in the last year: ( (12) ( Severe dizziness or imbalance (13) ( Persistent noises in your ear (tinnitus) ?how severe is it? (L)Mild (M)Moderate (S)Severe (Y)Unknown (10) ( Ear pain ?circle which ear Right Left Both Unknown (11) ( Ear drainage (Pus) ?circle which ear Right Left Both Unknown (14) ( Sudden hearing loss ?circle which ear Right Left Both Unknown (15) ( Fluctuating hearing loss ?circle which ear Right Left Both Unknown (16) ( Feeling of fullness in ear ?circle which ear Right Left Both Unknown (17) ( Ear problems when using hearing protectors ?circle which ear Right Left Both Unknown (20) ( Seen a physician for ears since last test ?circle which ear Right Left Both Unknown (23) ( Use a Hearing Aid ?circle which ear Right Left Both How long ____Yrs (37) (Noisy Hobbies???????????. ?Mark below all that apply (38) ( Listen to loud music/headphones (39) ( Shoot Rifles ( Shoot right-handed ( Shoot left-handed Please explain any Yes responses (include dates) (37) ( Use Power tools (37) ( Other (list) ____________________________ Medical History: Mark ONLY THE following conditions that you HAVE HAD IN THE PAST or CURRENTLY HAVE: (26) ( Measles (19) ( High blood pressure medication ( Hearing loss since birth or childhood (24) ( Mumps (29) ( Kidney disease (32) ( Family members with hearing loss (28) ( Diabetes (31) ( Allergies (22) ( Serious head injury/knocked unconscious (27) ( Meningitis (21) ( Ear surgery as an Adult (36) ( Noise exposure in the military (25) ( Scarlet fever Which ear? ( R ( L How many years were you in the military? _____ Hearing Protection Usage Information: WHEN YOU ARE AT WORK IN HIGH NOISE AREAS, how often do you wear your hearing protection? (Mark one) ( 0-10% ( 10-30% ( 30-50% ( 50-70% ( 70-90% ( 90-100% What type of hearing protectors do you wear at work? (Mark one or more) ( Plugs ( Muffs ( Plugs and Muffs together ( I do not use Hearing Protectors I acknowledge that the above information is accurate to the best of my knowledge and by signing below authorize the release of above information and hearing test results to my employer per federal OSHA requirements (29 CFR 1910.95). Employee signature: Date: BELOW IS FOR OFFICE USE ONLY??????????????????????????????????????????? Test Results: Examiner: Certification/License # ___________________________________________ Date of Test: Audiometer and Serial Number: _________ Otoscopic examination: (30) RIGHT: _________LEFT: Calibration Date: RIGHT EAR THRESHOLDS IN dB HL LEFT EAR THRESHOLDS IN dB HL 500 100020003000400060008000500100020003000400060008000 @Bbdhjt????????? 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