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WSU Occupational Medicine 3860 Robert C Byrd HSC Patient Label Morgantown WV 265069145 Phone Number: 3042933693 Fax Number: 3042932629 Hearing History Questionnaire A. Identification Date: Name: DOB:
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How to fill out a hearing history questionnaire:

01
Start by reading through the questionnaire carefully to understand the information required and the format of the questions.
02
Begin with providing your personal details such as name, date of birth, contact information, and any other requested information for identification purposes.
03
Move on to answering questions about your medical history related to hearing. This may include any past or current conditions, surgeries, or medications that may have impacted your hearing.
04
Indicate any family history of hearing loss or related conditions if asked.
05
Share your occupational or recreational noise exposure history, particularly if you have worked or participated in activities where loud noises were common.
06
Respond to questions regarding any symptoms or difficulties you have experienced with your hearing, such as hearing loss, tinnitus (ringing in the ears), or dizziness.
07
If applicable, mention any prior testing or evaluations you have undergone related to your hearing.
08
If the questionnaire asks about exposure to specific environmental or lifestyle factors that may affect hearing, provide relevant information.
09
Finally, review your answers and make sure you have filled out all the necessary sections of the questionnaire. Sign and date the form, as required.

Who needs a hearing history questionnaire?

01
Individuals seeking a hearing evaluation or treatment may need to complete a hearing history questionnaire. This can include those experiencing hearing loss, tinnitus, or other hearing-related issues.
02
Medical professionals, such as audiologists or otolaryngologists, often require patients to fill out a hearing history questionnaire to gather important information about their hearing health.
03
Employers or occupational health programs may also use hearing history questionnaires to assess noise exposure risks and facilitate hearing conservation efforts in the workplace.
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The hearing history questionnaire is a form used to gather information about an individual's hearing health and history.
Individuals who are undergoing hearing testing or treatment are typically required to fill out a hearing history questionnaire.
To fill out a hearing history questionnaire, you should provide accurate information about your hearing health, any previous hearing tests or treatments, and any family history of hearing issues.
The purpose of the hearing history questionnaire is to help healthcare providers better understand a patient's hearing health and history, which can aid in diagnosis and treatment.
Information such as past hearing issues, family history of hearing problems, exposure to loud noises, and any previous treatments or tests related to hearing should be reported on the hearing history questionnaire.
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