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Your Forename (required)

Your Surname (required)

Your Email (required)

Your Contact Number (required)

Have you claimed or tried to claim before for hearing loss/tinnitus?
  Yes   No

Have you been exposed to excessive noise after 1963?
  Yes   No

Have you been exposed to noise whilst serving in the armed forces?
  Yes   No

Were you exposed to noise whilst self employed?
  Yes   No

Have you worked in noise with more than 5 different employers?
  Yes   No

Did you work in a noisy environment for 2 years or more?
  Yes   No

Was the noise so loud you would have to shout to a colleague standing 6 feet away to be heard?
  Yes   No

Have you been diagnosed with hearing loss / tinnitus?
  Yes   No

Have you been advised your hearing problems are noise/work related?
  Yes   No

If yes, was this more than 3 years ago?
  Yes   No

Please indicate your age
  < 25   25-45   45-65   65-75   75 +

Best time to contact you

Do you suffer with any of the following symptoms?

Struggle to hear generally
  Yes   No

Your Family complain the TV or radio is too loud
  Yes   No

Do family members complain you can’t hear them
  Yes   No

Do you struggle to hear on the telephone
  Yes   No

Do you struggle to hear in crowded places
  Yes   No

Do you have a ringing or whistling in your ears
  Yes   No

Hearing Tests

Have you had any hearing tests in the last few years
  Yes   No

Was that at work
  Yes   No

Were you told any loss of hearing could be due to noise damage
  Yes   No

What type of industry did you work in:

If we are unable to accept your case are you happy for us to pass this information to another specialist firm of solicitors for a free second opinion?
  Yes   No

*Please Note: This information will not be used for any other purpose