Occupational Hearing Test Questionnaire and Consent Form

Please tick the options that apply. Only complete the detail fields if you select Yes or Other.

First Name*

Last Name

Email*

Date of Birth*

Employer / Site*

Test Date*

Case History Questions

How do you feel about your hearing?

No concerns

Some concerns

Significant concerns

Not sure

Prefer not to say

If you have concerns, please briefly describe

History of ear infections?

No

Yes - as a child

Yes - as an adult

Not sure

If yes, please provide details if you wish

Noise exposure (work or recreational)?

No

Yes - work related

Yes - recreational

Yes - both work and recreational

Not sure

If yes, please provide details if you wish

Family history of hearing loss?

No

Yes

Not sure

If yes, please provide details if you wish

Consent

I have given consent to an audiologist from Melody Hear For You to test my hearing. I understand that a hearing test report will be provided after the appointment.

I understand that all records are confidential and governed by the Privacy Act Provision of results to any other person or agency will require my written consent.

I have read and understood the above information and consent to the hearing test

I would like the clinician to contact me if follow-up is recommended

Worker signature*

✗

Date*