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INDUSTRIAL MEDICINE CONSULTANTS INC.
-----------------------------------
OCTOBER 1966
SHAWN BEARD JEFFERSON C
07/25/67
CBEARDS
06/09/86.
LABORER
LABORER
BASELINE
TEST LEFT EAR
DATE (KH)
.5 1. 2. 3. 4.
-------------------
10/30/86 10 5 0 10 10
-------------------
RIGHT EAR
(KH)
6. 8. .5 1, 2. 4. 6. 8.
-----------------------------------
0 5 5 5 5 0
ANNUAL
------------------------------------
INTERPRETATION
L-NORMAL
R-NORMAL
µ i F atue? i 51 a 5 FAUNA, Y9 T ! war
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EMPLOYEE HEARING QUESTIONNAIRE
DATE.
EMPLOYEE NAME `'fi`n"'•"• YnavS
z DATE OF BIRTH:
MEDICAL HISTORY
t
1. Have you or anyone eke noticed a problem with your hearing?
Who?
COMPANY:
HIRE DATE
JOB DESCRIPTION:
CIRCLE ONE
Yea `l
g. Have you ever had ear trouble as a child or adult? Vaa (90'
earlnfectlo"? Yea No
meatoldectomy? Yes No
atapedactomy? Yea No
Punctured eardrum? Yee No
other ear cperatlcos? Yes No
3 Have you ever had:
mumps?
maasiee ((Ygs No
1,
0
soadei love,? 0
No
Yes
other high iweq? Yee
a.Hwsyouwerbad ringllg, booing,orotherI,,-It nolea7 Yea
If m /or how long?
Q Have you ever boon ain¢k on the heaCl
Wero you unconscious? o
It so, how long?_ No
6. Have you suffered periods of dluIna" or loss of balance? Vae 10
For how long?
7. Have you gone to a doctor for hearing problems? Yea
No
What wars tot /Indings7
If
a Have any member of your family war had hearing problems before age 007
d ;ha No
W, daac
be:
IL Do you have a hearing ald? Vas No
WORK/EXPOSURE HISTORY
IQ Prbrloyourpresent employment hsveyouwwked Ina nokylnduetry? Vas No
Howlong? 00 year..
6.10 yesn.
10.10 years.
11. Did you wear hearing protection on the pre,lous ob? Yes No
What percentage of the tlme did you waMr it? 110.100%
70.00%
60.70%
60%
12 What kind of hearing protection device doyou use?
earwax.? Y.. CRS
muff.? r••}
v.nted plugs? Yea
What Wand rums?
molded plugs? ' `?y
Y.
IM Does your hearing Improve when you are away from the lob? Yes tt
06
ovsrnl0hq ?
..
Vea (d
day. ofr? Y. To
14. Off the fob have you been exposed to high noise? Ys. No
Deacrlbedher, How, long?
hunting?
Yea No
motorcyela? Yee No
snowmoblle? Yea No
Gain saw? No
• roctl rnu.lc?
V
a No
Do you wear hearing protection dudng then activities? other? N4
Yea Nb
Which activities? U
16. Have you ever had a hearing lest? N.
If sgwhen e?ppp vv//110,17
_111 huh Cr kda?
16. OsscrlWy re0 ring aMllry In our own wawa:
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