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Industrial Health 1644 Stone Street Port Huron MI 48060 tel 810 982-8016 fax 810 982-3590 Subject Hearing History Questionnaire Please fill out the information below Patient Name Social Security Number Sex Circle Please M / F Job Title Company Name Birth Date Hire Date Have you been exposed to loud noise in the last 14 hours without wearing hearing protection Circle Please Yes Type of hearing protection you use at work Circle Please Plugs / Muffs / Both How often do you wear hearing...
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