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Military Deafness Form
Military Deafness Form
Military Deafness Form
Step
1
of
6
- About You
16%
Name
(Required)
firstname
surname
Address Line 1
(Required)
Address Line 2
City
(Required)
Postcode
(Required)
Your Email Address
(Required)
Your Phone Number
(Required)
Date Of Birth
(Required)
DD slash MM slash YYYY
National Insurance Number
(Required)
Service
(Required)
What branch of the Services were you in - British Army, Navy or Airforce?
What were your dates of service?
When did you start your service?
When did you end your service?
(Required)
Service Number
(Required)
Are you left or right-handed?
(Required)
Right-handed
Light-handed
In what circumstances were you exposed to noise and when did this take place?
(Required)
What is the nature of your problems/symptoms? Eg hearing loss, ringing in the ears, hypersensitivy.
(Required)
What date did you first notice these symptoms?
(Required)
Do you have problems in your left or right ear or both?
(Required)
Left
Right
Both
Have the problems worsened?
(Required)
Yes
No
What do you think caused your hearing problems?
(Required)
Have you ever sought medical advice for your hearing problem? If so from whom?
(Required)
Have you been diagnosed with hearing loss / tinnitus or hyper-sensitivity (hyperacusis)?
(Required)
Hearing Loss
Tinnitus
Hyper-sensitivity (hyperacusis)?
I have not been diagnosed
What is the date you were diagnosed?
Who diagnosed (GP / Hospital / military doctor)?
GP
Hospital
Military Doctor
N/A
Did the medical professional discuss the cause of your hearing problem?
Yes
No
N/A
Approximately when (year and month if possible) did you connect your hearing problems to noise exposure in the armed forces?
What prompted you to make this connection?
Why have you not brought a claim earlier?
Have you worked anywhere else outside the armed forces where you may have been exposed to noise? If so please provide details?
Have you made a claim for your hearing loss under Armed Forces Compensation/ War Pension Schemes? If so what was the outcome?
Have you previously contacted a solicitor about your hearing loss claim? If so what was the outcome?
