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  • Mopani Copper Mines Audiological Questionnaire

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    Ntainda Kantalamba
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    This document contains an audiological questionnaire for employees at the Wusakile Mine Hospital. The 10-question form asks for an employee's name, date of birth, engagement date, present employment details, last shift details, history of noise exposure and hearing protection use, history of ear diseases, unconsciousness, and common illnesses. The form also includes a section for an otoscopic ear examination by a medical examiner to check for wax or infections before conducting an audiogram test.

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    Original Title

    PRE AUDIOMETRY QUESTIONIARE

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    This document contains an audiological questionnaire for employees at the Wusakile Mine Hospital. The 10-question form asks for an employee's name, date of birth, engagement date, present employment details, last shift details, history of noise exposure and hearing protection use, history of ear diseases, unconsciousness, and common illnesses. The form also includes a section for an otoscopic ear examination by a medical examiner to check for wax or infections before conducting an audiogram test.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views1 page

    Mopani Copper Mines Audiological Questionnaire

    Uploaded by

    Ntainda Kantalamba
    This document contains an audiological questionnaire for employees at the Wusakile Mine Hospital. The 10-question form asks for an employee's name, date of birth, engagement date, present employment details, last shift details, history of noise exposure and hearing protection use, history of ear diseases, unconsciousness, and common illnesses. The form also includes a section for an otoscopic ear examination by a medical examiner to check for wax or infections before conducting an audiogram test.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    MOPANI COPPER MINES PLC

    MEDICAL DEPARTMENT
    FM-ME-112
    GENERAL PURPOSE FORM

    WUSAKILE MINE HOSPITAL - AUDIOLOGICAL QUESTIONAIRE


    NAME:…………………………………………………COMPANY:………….COMPANY NO………….
    DATE OF BIRTH:………………………………….. DATE OF ENGAGEMENT ……………………………
    1. TEST TYPE REQUIRED (TICK)
    (a) Baseline audiogram
    (b) Annual (Screening) Audiogram
    (c) Diagnostic/screening Audiogram
    2. PRESENT EMPLOYMENT:…………………………………….. NO. YEARS:…………………………
    3. LAST SHIFT KNOCK OFF DATE: …………………………………….. TIME: ……………………….
    4. DO YOU HAVE TO SHOUT TO MAKE YOURSELF HEARD AT WORK? (Tick)
    (a) AII the time (b) Occasionally (c.) Never
    5. PRIOR TO PRESENT JOB, HAVE YOU WORKED ON A NOISE JOB WHERE YOU HAD TO
    SHOUT TO MAKE YOURSELF HEARD? (Tick) YES/NO
    IF YES, LIST BELOW ALL PREVIOUS JOBS AND WORKED:
    ………………………………………………………………… NO. OF YEARS:………………………..
    …………………………………………………………………. NO. OF YEARS………………………..
    ………………………………………………………………… NO. OF YEARS:………………………..
    ………………………………………………………………… NO. OF YEARS:………………………..
    6. HAVE YOU EVER WORN HEARING PROTECTION? (Tick) YES/NO
    IF YES, WHICH JOB? ……………………… TYPE OF PROTECTION:…….…………………………
    7. HAVE YOU EVER USED FIREARMS? (Tick) YES/NO
    IF YES, HOW LONG?………………………………………………………………………………………..
    8. HAVE YOU EVER SUFFERED AN EAR DISEASE? (EXAMPLE: DISCHARGE/BLEEDING) (Tick)
    YES/NO
    IF YES SPECIFY:……………………………………………………………………………………………
    9. HAVE YOU EVER BEEN UNCONSCIOUS? (Tick) YES/NO
    10. HAVE YOU EVER SUFFERED ANY OF THE FOLLOWING:-
    MEASLES/MUMPS/MENINGITIS/CEREBRAL MALARIA/SYPHILIS/HIV/AIDS/DRUG
    POISONING/DIABETIS MELLITUS…………………………………………………………………………..
    OTOSCOPIC EXAMINATION

    DATE:…………………………………………………

    RIGHT EAR:
    ………………………………………………………………………………………………………………………
    LEFT EAR:…………………………………………………………………………………………………………
    COMMENTS:
    ………………………………………………………………………………………………………………………
    ……………………………………................................................................................................................
    ...........................................................................................................................................
    ………………………………………………………………………………………………………………………
    ……………………………………

    EXAMINER’S NAME:……………………………………………
    SIGNATURE………………………………………………………….

    NB: TREAT WAX IMPACTION AND EAR INFECTION BEFORE


    AUDIOMETRY. REFER TO LOCAL CLINIC/HOSPITAL.

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