af1753.pdf

HEARING CONSERVATION EXAMINATION

(This form is subject to the Privacy Act of 1974 - Use Blanket PAS - DD Form 2005)

(Instructions - complete the information in the lower right corner of the form. Answer all questions in section I only. Enter your signature after you have been informed of the results of your hearing test.)

DATE

SECTION I - AUDIOMETRIC CASE HISTORY

OTHER (specify) ANNUAL 1. What kind of hearing test are you getting today? REFERENCE TERMINATION

YES YES NO NO

DON'T

KNOW

DON'T

KNOW

2. Have you been exposed to loud noise in the last 15 hours?

G. Frequent ear infections?

H. Ringing in ears?

3. Do you have any difficulty hearing:

I. Dizziness?

A. Warning bells or sirens?

9. Have you ever been removed from a job or denied a job because of your hearing? B. Over The Phone?

C. In Noisy Rooms? * 10. Have you ever been restricted from exposure to noise (Even temporarily)

D. Normal Speech? because of your hearing?

4. Is your hearing getting worse? * 11. Do you now have, or have you ever had repeated exposures to noise from 5. Is one ear better than the other? *

6. Does your hearing frequently change? A. Snowmobiles?

7. Do you now have: B. Motorcycles?

A. A hearing loss of any kind? C. Loud Music?

B. A hearing aid? D. Firearms?

C. Pain in your ears? E. Farm Equipment?

D. An ear infection? * F. Construction Equipment?

E. Drainage from ears? * G. Chain Saws?

H. Power Tools? F. Trouble with wax in your ear?

G. Trouble wearing ear plugs? 12. What kind(s) of hearing protection do you have?

H. Pressure in ears? *

8. Have you ever had A. None

A. Ear surgery? * B. Single Flange Plugs

B. Allergies? C. Triple flange plugs

C. Measles? D. Foam plugs

D. Mumps? E. Ear muffs

E. Diabetes? G. Other

F. Sinus Problems? 13. Do you need new ear plugs?

CERTIFICATION OF PATIENT/EXAMINER'S SIGNATURE

I certify that I have read the information in the above case history. It is accurate to the best of my knowledge, and I acknowledge having been informed of my hearing test results and understand the requirement to wear hearing protection when exposed to hazardous noise.

PATIENT'S SIGNATURE EXAMINER'S SIGNATURE

AUDIOGRAM

RESULT H-2 OR WORSE CHANGE: STABLE STS*PROFILE: H-1 or BETTER

DATE SECTION If - CLINICAL EXAMINATION (Completed by provider) REQUIRED NOT REQUIRED * A clinical examination and/or more detailed history must be performed by a provider if an asterisked response is checked.

REMARKS

INSPECTION/EVALUATION NORMAL ABNORMAL

NOT

EXAMINED

OUTER EARS (Pinnas)

EAR CANALS

TYMPANIC MEMBRANES

MIDDLE EAR

EUSTACHIAN TUBE FUNCTION

NOSE

THROAT

PERFORM FITNESS AND

RISK EVALUATION

PROVIDER'S SIGNATURE

CLEAR FOR DUTY

DISPOSITION

OTHER (Specify) REFER FOR EARPLUG

FITTING

PATIENT IDENTIFICATION PATIENT'S NAME

SSN GRADE/RANK AGE

ORGANIZATION

PAS CODE

AF IMT 1753, MAY 91, V1

11.0.1.20130826.2.901444