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The questionnaire below should be completed as fully as possible. All questions must be
answered. The information will be treated in the strictest confidence.
WARNING: In completing the questionnaire, you are responsible for the accuracy of your statements. If
information is withheld suppressed, deliberately misleading or false, you may be held liable and this may
become a cause for your dismissal.
1. HEIGHT: WEIGHT:
2. Do you presently suffer from an illness requiring medication? YES: NO:
3. Do you presently suffer from an illness requiring hospital visit? YES: NO:
4. Do you smoke? YES: NO:
5. Do you wear glasses or contact lenses? YES: NO:
6. Is your sight in each eye good enough for all activities?
(If glasses or lenses are necessary, please indicate the grade and
kind of glasses/lens used in the space provided in page two). YES: NO:
7. Is your hearing in each ear good enough for all normal activities? YES: NO:
(If hearing aides are necessary, please explain in the space
provided in page two, which ear (right/left) is affected and what
type of hearing aide you are using).
8. Do you have a discharge from either ear?
9. Please complete the following questions 1-31 by checking the appropriate lines.