Military Deafness Form - Watkins & Gunn

Name(Required)

Address Line 1(Required)

Address Line 2

City(Required)

Postcode(Required)

Your Email Address(Required)

Your Phone Number(Required)

Date Of Birth(Required)

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?

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