Pre Employment Physical Examination Form Page 3
ADVERTISEMENT
1
2
3
4Pre-Employment Physical Examination
Section 2 Audiometry Test (to be completed by Audiometrist)
Name of applicant:
_____________________________________________________________
Date completed:
_____________________________________________________________
Have you been required to wear hearing protection in any previous roles?
Yes
No
If yes:
1.
Employers Name:
______________________________________________________
Dates employed:
______________________________________________________
2. Employers Name:
______________________________________________________
Dates employed:
______________________________________________________
Have you had any of the following?
Pain in the ears
Yes
No
Discharge from the ears
Yes
No
Ringing in the ears
Yes
No
Loss of balance
Yes
No
Dizzy spells
Yes
No
Head injury / concussion
Yes
No
Family history of ear problems
Yes
No
Military service
Yes
No
Exposure to gunfire (recreational)
Yes
No
Noisy hobbies
Yes
No
Scuba diving
Yes
No
Have you had any other problems associated with your ears?
Yes
No
If yes, please specify
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Signed (Audiometrist):
_____________________________________________________________
Printed name:
_____________________________________________________________
Date completed:
_____________________________________________________________
Pre-Employment Physical Examination Form
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical