HomeMy WebLinkAboutReel_0024C (40)h'd?,° M .rI t t i
INDUSTRIAL MEDICINE
CONSULTANTS INC.
P. 0. BOX 1980
EVERETT, WA. 98206
JUNE 1986 D' ." .
t
DEAR ALVIN ACKERMAN
THE RESULTS OF YOUR RECENT HEARING TEST ARE:
HEARING LOSS IN BOTH HIGH FREQUENCY AND
SPEECH RANGE IN LEFT AND RIGHT EARS.
`t LOSS MAY INTERFERE WITH NORMAL SOCIAL AND FAMILY
INTERACTION.
REMEMBER THAT YOU SHOULD BE USING PROPER
HEARING PROTECTION WHEN YOU ARE EXPOSED TO HIGH
LEVELS OF NOISE, BOTH AT WORK AND AT HOME.
ANY QUESTIONS RELATING TO HEARING PROTECTION
SHOULD BE DIRECTED TO YOUR SUPERVISOR.
HEARING CONSERVATION CONSULTANTS:
J.P.LYNCH,M.D., OTOLARYNGOLOGIST
MICHAEL MALLAHAN, AUDIOLOGIST
PACIFIC EAR, NOSE, AND THROAT CLINIC
1515 PACIFIC 252-1650
EVERETT, WASHINGTON 98201
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INDUSTRIAL-hIEDICINE-CONSULTANTS-INC.
--------------------------------
JUNE 1986
Y
NAME ALVIN ACKERMAN
BORN 09/01/24 JEFFERSON C
I.D. NUMBER CACKERAL
HIRED 03/01/72
JOB DESCRIPTION EOU!P i
JOB LOCATION
EQUIP g
BASELINE
TEST LEFT EAR
DATE ( KH) RIGHT EAR INTERPRETATION
(KH)
5 1. 2. 3. 4. 6. S. 5 I. 2. S. 4. 6. 8.
-------------------------- ---
06104186 10 25 10 45 60 70 15 10 25 45 35 60 L-HI FRO & SP
R-HI FRO & SP
ANNUAL
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EMPLOYEE HEAR114G QUESTIONNAIRE
.,? DATE:
k EMPLOYEE NAME: ? :!'? \ • • COMPANY:
DATE OF BIRTH: P (/\ J5\N''/X HIRE DA -
JOB DESCRIPTION: /Xf.LIAY /5/ C
wt MEDICAL HISTORY
CIRCLE ONE
Y lu I. Have you or anyone 8130 noticed a Problem with your hearing?
k"?L Who? Yee
G {' F
i 2 Have you ever had ear trouble as.child-clult? Yes
earinfectlon?
Yea
msatoldectomy? Yea
etapadx' myJ i
Punctured eardrum? Yes /NO"
other ear Yea No
openllou7 Vee CNO
^i f 3 Have you ever had: p ,
22ni
pY Un;P.?
` a No
s,r a,u f ? audit fever? .a N'.
?'°csa ( ?` otherhighlevers? Yea o.
'IN 4. Have you ever had dngln0. b-In%or other types of ear nolae?
If so, forhow long! Yea
-ry ?f ? I 6. Have You ever been atruokonth head?
Wore YODUnconecloua? Yea \n"N?cI
Ilao'll"long? Yea
r+ jY 6. For how long/ red psdotla pf dissiness or Ions of bal.nceT Yee lll?JJl d
{-? 7. Have You pone to a doctor for hearing problems?
What were the findings? Vea. N?
_ vr5 .,,3 B. Have any members of your family ever had hearing problems before so&Sly,
I If so, describe: Yes
9. Do you have a hearing aid? -
Yea
WORK/EXPOSURE HISTORY 10. Prior to Your Present employment have 1J 1+?k. How long! You worked iris no4Y industry? Yea
06 Year.
610 Years.
i 7C 3i? _r 1016 years
' Y ,w l1MM -` 11. Did you wear hearing Protection on the previous job?
What peru111s0ed11e time did you weer it? Yoa No
76180%
{ } ?" 6076%
y 60% ) k'+Jn
17. What kind or hearing Protecllon device do you use? t tt
sarpluge? Yea
mu
Yea No
`I I 6a? pigs?
.riled Yea No ''r
f}F What brand ume7 molded plugs? Yes No ,5 •.
13. Does '.?•<
your hearing Improve when you an away from the lob? Yea trio
b overnight? Yes INo 1
" daY. of" yea l NJ
ta. Off USJob have YOU been sapoNdto high no4s?
Yes
Yea
Describe other. How long? No hurlIng?
motorcycle? ?_ Yn No
,f 1 (r 1 t I anowmoNls7 Yes No
J 1.5 y r C J chain a..? Yu No
ee rock muelC? Yea No ?I
)^ } 9 r ; Do you wear Msrlrp polactbn during thou edlMtlaT olha(7 Yea No /
s v t } Which activities? Yea No + k ?
{i 1 'U7I f { 16. Hm you =had ehgMplnYl ?
I 4
R.gwhehere? Yn No
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