Questionnaire for Hearing Test

Answering this questionnaire is optional. You can read about our protection of your personal data here.

If there are questions you can’t or don’t want to answer, just skip to the next question.
If you would like a copy of your reply sent to your mail, please fill in the Email field below (Might be in the Spam folder).

Hearing Test
First Name / Last Name - or an Alias.
City / Branch
Example: 1970
Optional: Your E-mail if you want a copy of your answers.
Noise environment
What is the noise level where you normally work?
1. Have you previously, in other companies, been exposed to noise at work so that normal conversation could not be heard?
3. Have you been exposed to loud noise in your free-time for longer periods? (Eg loud music, hunting, self-forestry)
4. In your current job, are you exposed to annoying noise?
5. In your current job, are you exposed to noise for extended periods of time so that normal conversation cannot be heard?
6. Are you exposed to sudden or unexpected loud noises in your daily work?
Use of protective equipment
7. What hearing protection do you use?
7a. How consistently do you use protective equipment (regardless of type)?
Consequences / Injuries
8. Do you think that you have had a hearing loss due to work?
9. If "Yes" in question 8: Have you notified the hearing impairment to the Danish Working Environment Authority or the National Insurance Agency?
10. Have you had a hearing impairment to such an extent that you have difficulty following a conversation when there are several people together?
11. Have you, within the last 3 months, had ringing or whistling in your ears?
12. When you hear daily noises such as chairs being moved, the clatter of cutlery, bright voices, how often do you feel discomfort or pain?
13. Have you had ear infections or other illnesses that have affected your hearing?
If "Yes" in question 13:
14. Does anyone in your immediate family have poor hearing? (parents or siblings)
15. Do you use a hearing aid, or have you been offered one?
Work Environment Work
16. Has your employer / environmental representative instructed you on the health risks arising from noise?
17. How often has your employer / environmental representative pointed out your, or your colleagues', lack of use of protective equipment?
18. How often have you - to your colleague - pointed out your the colleague's lack of use of protective equipment?
19. Can you do something yourself to reduce the exposure to noise, e.g. change working method?
AG Sundhedsfremme ApS uses your answers, combined with the measured health data in the upcoming examination, to advise you about your health. The answer will, in anonymized form, also be included in a comprehensive report to the company, however in such a way that no individuals can be identified. By giving your consent for the above purposes, you are at the same time giving AG Sundhedsfremme's nurses and statisticians the right to process your information in this questionnaire. You can always withdraw your consent by writing to