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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
No
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
Never wear
Please check
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
(4) Tinnitus
Yes
No
Yes
No
Yes
No
Yes
No
(8) Meningitis
Yes
No
(9) Tuberculosis
Yes
No
No
Yes
No
Yes
No
year(s)
year(s)
Yes
No
(2) Tinnitus
Yes
No
(3) Dizziness
Yes
No
No change
Improved
3. Since your last hearing test (since last year), have you
(1) Been exposed to an explosion?
Yes
No
Yes
No
Yes
No
No
No
No
4. Since your last hearing test, do you have the following conditions?
Yes
(1) Ear injury
No
Yes
No
Yes
No
(4) Tinnitus
Yes
No
Yes
No
Yes
No
Yes
No
(8) Meningitis
Yes
No
(9) Tuberculosis
Yes
No
Yes
No
Worsened