Hearing History Form

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The deadline for online questionnaire submissions for employees being tested at our mobile units is a week prior to the start of the job. Be aware that we cannot access any forms after the deadline on the mobile units and paper copies will need to be completed.
Alliance Health Resources Mobile Division Ltd. | 2910 Center St
Deer Park, TX | 77536 | 281.479.6672

The following form is for office personnel and account setup purposes. It is not intended to be a means to contact Alliance Health Resources for emergency medical needs. If your matter is urgent, please call 911.

Phone
This field is for validation purposes and should be left unchanged.
Company*
SSN*
Employee ID
Name*
First Last
Email*

Your results may be sent to you by email. Please provide an email for which you can receive your results.
Birth Date*
Month
Day
Year
Gender*
Status
In Program
Hire Date*
Month
Day
Year
Language*
Comment
Have you recently experienced pain in either ear?*
Have you recently experienced a draining ear?*
Have you recently experienced a dizziness?*
Have you recently experienced severe tinnitus (ringing)?*
Have you recently experienced sudden hearing loss?*
Have you recently experienced fluctuating hearing loss?*
Have you recently experienced ear fullness or discomfort?*
Have you recently had problems wearing hearing protection?*
Have you ever served in the military?*
Have you ever been to a doctor for an ear-related problem?*
Have you ever had a severe head injury?*
Have you ever had ear surgery?*
Have you ever had an ear injury?*
Have you ever had measles?*
Have you ever had mumps?*
Have you ever had kidney disease?*
Have you ever had scarlet fever?*
Have you ever had meningitis?*
Do you have diabetes?*
Do you have high blood pressure?*
Do you have an existing hearing problem?*
Do you have frequent ear infections?*
Do you shoot guns or hunt?*
Do you wear a hearing aid?*
Do you participate in loud activities (music, motorcycle)?*
Do you currently use prescription or over the counter drugs?*
Are you currently suffering from allergies?*
Does any of your immediate family have hearing problems?*
Signature

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Hearing
History Form