02.
Noisy work questionnaire
Instructions
1. Employees should fill in the six items of demographic data, working experience, examination time, past
medical history, living habits and self-perceived symptoms before the workers health examination. Then it
should be submitted to the health care workers for confirmation and to screen out disease effectively. If the
working unit has provided the electronic files of demographic data and working experience of the employees
to the designated medical institutions, the employees should not be asked to fill them in repeatedly.
2. For self-perceived symptoms, the employees should check the symptoms according to their actual symptoms.
I. Demographic data
1. Name
2. Sex Male Female
3. ID card number (passport number)
4. Date of birth______Year_____Month_____Date
Date
5. Date of employment____Year___ Month
6. Date of examination
Year
Month
Date
II. Working experience
1. Had worked for
,
Since (date)____Year____Month, Until (date)____Year____Month, Total
Year (s)
Month (s)
2. Is working for
,
Since (date)____Year____Month, Until (date)____Year____Month, Total
Year (s)
Month (s)
3. To learn more about your work experience, please answer the following questions
(For first health examination, please fill in 3.1 to 3.2; for regular health examination, please fill in 3.2 to 3.3)
3.1 Have you engaged in work in the following industries?
Textiles
Mining
Shipbuilding
Heavy industry
Road construction
Artillery force, shooting team, aviation ground support
Other work that requires shouting over noise
3.1.1 If you have engaged in any of the work above
(1) Did you have hearing protection measures? Yes
No
(2) Did you wear hearing protection devices? Yes
No
(3) What were the protection devices?
Ear caps Earplugs Both
3.1.2 If you have engaged in any of the work above, what were the working hours and hours of noise?
(1) Average daily working hours ? 10 hours 8 hours 6 hours 4 hours
(2) Hours of noiseAll working hours Half of the time Occasionally
3.2 Have you been to a noisy area within the last 14 hours? Yes No
3.3 If you work in a noisy area, do you wear hearing protection devices?
Yes (Please answer the following two questions)
No
(1) If you wear, what type is it? Ear caps Earplugs
Both
(2) Wearing time Wear all the time
Wear half of the time
III. Past medical history
Never wear
Please check
1. Have you been to a hospital and asked a specialist to check Yes
your ears or hearing?
2. Have you ever
Yes
(1) Been exposed to an explosion?
No
(2) Been exposed to great noise?
Yes
No
(3) Had direct ear injury?
Yes
No
(4) Been exposed to practical gunshots regularly?
Yes
No
(5) Been exposed to loud music regularly? (popular music, Yes
Peking opera)
3. Have you had the following conditions?
Yes
(1) Ear injury
No
No
(2) Had ear surgery
Yes
No
(3) Ear infection
Yes
No
(4) Tinnitus
Yes
No
(5) Tympanic membrane perforation
Yes
No
(6) Earache caused by blasting
Yes
No
(7) Use of ototoxic drugs such as aspirin, streptomycin
Yes
No
(8) Meningitis
Yes
No
(9) Tuberculosis
Yes
No
No
(10) Concussion or coma
4. Do you have a family medical history of hearing impairment?
Yes
No
Yes
No
If yes, please specify
IV. Living habits
1. Do you have the following hobbies? mutiple choice
Go to disco, karaoke or pop concerts
Car racing (have competition or viewing)
Perform in a brass band, orchestra or pop band
Frequent use of electrical hand tools, such as saws, drills, etc.
Use machines for garden maintenance
Shooting
Use a walkman or a similar device to listen to music
2. Have you smoked in the past month? single choice
Never smoke
Smoke occasionally (not daily)
(Almost) smoke daily, average smoke cigarette(s) daily, smoke for
Quit smoking, quit for year(s) month(s)
3. Have you chewed betel nut in the past six months?single choice
Never chew
Chew occasionally (not daily)
(Almost) chew daily, average chew ___betel nut(s) daily, chew for
Quit chewing, quit for year(s)
month(s)
year(s)
year(s)
4. Have you drank alcohol in the past month? single choice
Never drink
Drink occasionally (not daily)
(Almost) drink daily, average drink time(s) weekly, drink____most often, ___ bottle(s) each time
Quit drinking, quit for year(s) month(s)
V. Self-perceived symptoms
For first health examination, please fill in question 1; for regular health examination. please fill in question 2~4
1. Do you have the following symptoms?
(1) Hearing difficulty
Yes
No
(2) Tinnitus
Yes
No
(3) Dizziness
Yes
No
If yes, do you know the causes? Please specify_______________________
2. After your last hearing test, your (perceived) hearing has
No change
Improved
3. Since your last hearing test (since last year), have you
(1) Been exposed to an explosion?
Yes
No
(2) Been exposed to great sound?
Yes
No
(3) Been exposed to practical gunshots?
Yes
No
(4) Been Exposed to loud music, such as walkman, popular Yes
music, regularly?
(5) Been to a hospital and asked a specialist to check your ears or Yes
hearing?
(6) Used earplugs or ear caps when you are working in a noisy Yes
area most of the time?
No
No
No
4. Since your last hearing test, do you have the following conditions?
Yes
(1) Ear injury
No
(2) Ear surgery
Yes
No
(3) Pus or liquid discharge of the ear / ear infection
Yes
No
(4) Tinnitus
Yes
No
(5) Tympanic membrane perforation
Yes
No
(6) Earache caused by blasting
Yes
No
(7) Use of ototoxic drugs
Yes
No
(8) Meningitis
Yes
No
(9) Tuberculosis
Yes
No
(10) Concussion or coma
Yes
No
Worsened
