6 Hearing Exam

ID NUMBER:

FORM CODE: HEE VERSION: A 7/04/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 02 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

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

Hearing Exam Form (HEE) Page 2 of 3