6 Hearing Exam

The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Hearing Exam Qx_07-04-07

Focus Groups

OMB: 0925-0584

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ID NUMBER:










FORM CODE: HEE

VERSION: A 7/04/07

Contact

Occasion



SEQ #








OMB#: 0925-XXXX

Exp. XX/XXXX




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H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Hearing Exam Questionnaire


ID NUMBER:










FORM CODE: HEE

VERSION: A 7/04/07

Contact

Occasion



SEQ #





Acrostic:









Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year


Instructions: No proxy respondents. These questions must be asked before the hearing examination begins. Encourage participants to select the answer that best fits their experiences. Mark only one response per item.


A. Self Assessed Hearing Loss

1. Do you feel you have a hearing loss? No 0 GO TO QUESTION 5

Yes 1

Don’t know/refused 9 GO TO QUESTION 5


2. Which is your better ear? Left 1

Right 2

No difference 3

Don’t know/refused 9


3. Was your hearing loss sudden or gradual?

Sudden 1

Gradual 2

Don’t know/refused 9


4. How old were you when your hearing loss developed?

Less than 5 years old 1

5 to 19 years 2

20 to 29 years 3

30 to 39 years 4

40 to 49 years 5

50 to 59 years 6

60 to 69 years 7

70 years or more 8

Don’t know/refused 9

B. Tinnitus

5. In the past year have you had buzzing, ringing, or noise in your ears?

No 0 GO TO QUESTION 10

Yes 1

Don’t know/refused 9 GO TO QUESTION 10


6. Does this noise usually last longer than 5 minutes?

No 0 Yes 1 Don’t know/refused 9

7. Do you hear this noise only following very loud sounds (i.e. concerts, shooting, or noise at work)? No 0 Yes 1 Don’t know/refused 9


8. Does this noise cause you to have problems getting to sleep?

No 0 Yes 1 Don’t know/refused 9


9. In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears or head?

Almost always 1

At least once a day 2

At least once a week 3

At least once a month 4

Less than once a month 5

Don’t know/refused 9

C. Hearing Medical History

10. When was the last time you saw a doctor or other health care professional about any hearing or ear problems?

Never 0

Past year 1

1 to 2 years 2

3 to 4 years 3

5 to 9 years 4

10 to 14 years 5

15 years or more 6

Don’t know/refused 9


11. When was the last time you had your hearing tested?

Never 0

Past year 1

1 to 2 years 2

3 to 4 years 3

5 to 9 years 4

10 to 14 years 5

15 years or more 6

Don’t know/refused 9


12. Have you ever had surgery on your ears?

No 0 GO TO QUESTION 14

Yes 1

Don’t know/refused 9 GO TO QUESTION 14


13. What type of surgery was done? Tympanoplasty 1

Mastoidectomy 2

Stapedectomy 3

Cochlear implant 4

Other 5


14. Have you ever had tubes in your ears? No 0 GO TO QUESTION 16

Yes 1

Don’t know/refused 9 GO TO QUESTION 16

15. Do you have tubes in now? No 0

Yes, on right 1

Yes, on left 2

Yes, one (side unknown) 3

Yes, both sides 4

Don’t know/refused 9


16. Have you ever had an acoustic neuroma?

No 0 Yes 1 Don’t know/refused 9


17. Have you ever had a cholesteatoma?

No 0 Yes 1 Don’t know/refused 9


18. Has a doctor ever told you that you have Meniere’s Disease?

No 0 Yes 1 Don’t know/refused 9


19. Has a doctor ever told you that you have otosclerosis?

No 0 Yes 1 Don’t know/refused 9


20. Have you had a cold, sinus problem, or earache in the last 24 hrs?

No 0 Yes 1 Don’t know/refused 9


21. Have you been exposed to loud music or listened to music with headphones in the past 24 hours?

No 0 Yes 1 Don’t know/refused 9


22. Have you been exposed to any other loud noise in the past 24 hours?

No 0 Yes 1 Don’t know/refused 9




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