42 Additional Audition Olfaction Taste

Attachment 42
Additional Audition Olfaction Taste Questions

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Additional Audition Olfaction Taste Questions
Estimated time burden: 3 minutes
Additional Audition Olfaction Taste Questions - Adults and Children 10-17
[00-ATO-self]
On the next screens, we will ask you questions about your health and health-related
behaviors. Consider each question by itself, then choose or type in an answer that best
shows your experience.
After you make your choice, click on the NEXT button to go on to the next question. If you
want to change your last answer, click on the GO BACK button to return to the previous
question and then choose or type in a different answer. 1
Click on the CONTINUE button when you are ready to begin.

[01- ATO- Self]
Please select all that apply.
Has a doctor, nurse, or other medical professional told you that you have...
Glucose-6-phosphate dehydrogenase deficiency?
Myasthenia gravis?
[02- ATO- Self]
Please select all that apply.
Have you ever experienced any of the following?
Head injury
Loss of consciousness associated with head injury
Facial injury
Amnesia (memory loss of events surrounding injury)
Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Jaw surgery
Third molars (wisdom teeth) removed
Mouth or throat cancer
Chemotherapy
3 or more ear infections
Earaches or plugged feeling in ears
Ear tubes inserted
Dental trauma
Tonsillectomy
Severe gastrointestinal illness, as indicated by frequent vomiting, diarrhea, or dehydration
Sneezing, itchy nose
Prolonged, abnormal nasal discharge
Trouble breathing through nose
Postnasal drip
Sinus pain or headache
Nasal polyps
Deviated septum
Nosebleeds
Broken nose
Persisting allergic rhinitis (nasal allergy)
Vasomotor rhinitis
Other nasal or sinus problems
Injury of the nose or face

[03- ATO- Self]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Do you currently smoke?
No
Yes
[03a- ATO- Self]
If yes, how many cigarettes per day?

[05- ATO- Self]
Do you drink caffeinated beverages?
No
Yes
[06- ATO- Self]
How many hours did you sleep last night?

[07- ATO- Self]
Are you taking the sleep aid Lunesta®?
No
Yes
[08- ATO- Self]
Are you taking any medications that may interfere with your taste?
No
Yes

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[09- ATO- Self]
Have you been to the dentist in the last 48 hours?
No
Yes
[10- ATO- Self]
Select ALL of the following statements that apply to you now:
I have a normal sense of smell
My sense of smell is distorted, that is, things smell peculiar
I experience a smell when nothing is there (phantom smell)
My sense of smell is heightened (hypersensitive)
My sense of smell is diminished (partial loss)
My sense of smell is absent (complete loss)
[11- ATO- Self]
Compared to others your age, how would you rate your sense of smell?
Excellent
Good
Fair
Poor
[12- ATO- Self]
Have you noticed any recent change in your ability to detect odors?
No change in my ability to detect odors
Slight decrease in my ability to detect odors
Moderate decrease in my ability to detect odors
Severe decrease in my ability to detect odors

[14-ATO-self]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
How often do you find it difficult to follow a conversation if there is background noise, for
example, when other people are talking, TV or radio is on, or children are playing?
Always
Usually
About half the time
Seldom
Never
Don't know
[17-ATO-self]
Have you ever used assistive listening devices (ADLs), such as FM systems, closedcaptioned television, amplified telephone, relay services or a sign-language interpreter?
Yes
No
Don't know
[18-ATO-self]
In the past 12 months, have you been bothered by ringing, roaring, or buzzing in your ears
that lasts for 5 minutes or more?
Yes
No
Don't know

[18a -ATO-self]
How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
Less than three months

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Three months to a year
One to four years
Five to nine years
Ten or more years
Don't know
[18b-ATO-self]
In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears
or head?
Almost always
At least once a day
At least once a week
At least once a month
Less frequently than once a month
Don't know
[18c-ATO-self]
How much of a problem is this ringing, roaring, or buzzing in your ears or head?
No problem
A small problem
A moderate problem
A big problem
A very big problem
Don't know
[19-ATO-self]
Have you ever used firearms for any reason?
Yes
No

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[20-ATO-self]
Have you ever had a job where you were exposed to loud sounds or noises for 4 or more
hours a day, several days a week? Loud means so loud that you must speak in a raised
voice to be heard.
Yes
No
Don't know
[20a-ATO-self]
For how many months or years have you been exposed to loud sounds or noises for four or
more hours a day, several days a week?
Less than 3 months
Three to eleven months
One to two years
Three to four years
Five to nine years
Ten to fourteen years
Fifteen or more years
Don't know

[21-ATO-self]
In your work, were you exposed to a very loud noise? Very loud noise is a noise that is so
loud you have to shout to be understood or heard by someone standing three feet away
from you.
Yes
No
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[21a-ATO-self]
How many months or years did you work in jobs where you were exposed to very loud
noise, several days a week?
Less than 3 months
Three to eleven months
One to two years
Three to four years
Five to nine years
Ten to fourteen years
Fifteen or more years
Don't know
[22-ATO-self]
Outside of a job, have you ever been exposed to very loud noise or music for 10 or more
hours a week? This is noise so loud that you have to shout to be understood or heard by
someone standing three feet away from you. Examples are noise from power tools, lawn
mower, farm machinery, cars, trucks, motorcycles, motorboats or loud music.
Yes
No
Don't know

[23-ATO-self]
In the past 12 months, how often did you wear protection devices (ear plugs, ear muffs)
when exposed to very loud sounds or noise? Please include both on-the-job and off-the-job
exposures.
Always
Usually
About half the time
Seldom
Never

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
No noise exposure in the past 12 months
Don't know
[25-ATO-self]
Have you ever had a job or a hobby where you were regularly exposed to any of the
following? Check all that apply.
Herbicides/Pesticides
Acid or welding fumes
Industrial solvents or cleaning products
Cigarette smoke
Metal dusts
Wood dusts
Formaldehyde
Glues or adhesives

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[26-ATO-self]
During the past 12 months, how would you rate your sense of taste for salty, sour, sweet or
bitter things?
Excellent
Good
Fair
Poor
I have lost my sense of taste
Don't know
[27-ATO-self]
During the past 12 months, have you had any of the following problems with your sense of
taste? Check all that apply.
Can't taste some things
Can't taste most things
Some things don't taste right
Taste things when nothing should be there
Things taste stronger than they should
None of these problems

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[27a-ATO-self]
(if answered anything other than none of these or don't know)
How long have you had a problem with your sense of taste?
Less than three months
Three to eleven months
One to four years
Five to nine years
Ten or more years
Don't know
[28-ATO-self]
In the last 12 months, have you had pain or burning in the mouth or tongue not due to
mouth sores?
Yes
No
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Additional Audition Olfaction Taste Questions - Proxy Report for Children 10-17
[00-ATO proxy]
On the next screens, we will ask you to answer questions about your child and his/her
health and health-related behaviors. Consider each question by itself, then choose or type
in an answer that best shows your child’s experience.
After you make your choice, click on the NEXT button to go on to the next question. If you
want to change your last answer, click on the GO BACK button to return to the previous
question and then choose or type in a different answer.
Click on the CONTINUE button when you are ready to begin. 2
[01- ATO- Proxy]
Please select all that apply.
Has a doctor, nurse, or other medical professional said that your child has...
Glucose-6-phosphate dehydrogenase deficiency
Myasthenia gravis
[02- ATO- Proxy]
Please select all that apply.
Has your child ever experienced any of the following?
Head injury
Loss of consciousness associated with head injury
Facial injury
Amnesia (memory loss of events surrounding injury)
Jaw surgery
Third molars (wisdom teeth) removed

Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Mouth or throat cancer
3 or more ear infections
Earaches or plugged feeling in ears
Ear tubes inserted
Dental trauma
Tonsils or adenoids removed
Severe gastrointestinal illness, as indicated by frequent vomiting, diarrhea, or dehydration
Radiation treatment
Chemotherapy
Used firearms for target shooting, hunting, or for any other purposes
Had a job where he/she was exposed to loud noise for 5 or more hours a week (loud noise
meaning noise so loud that you had to speak in a raised voice to be heard)
Outside of a job, been exposed to steady loud noise or music for 5 or more hours a week
(examples are noise from power tools, lawn mowers, farm machinery, cars, trucks,
motorcycles or loud music)
Worn hearing protection when exposed to these loud noises
Sneezing, itchy nose
Prolonged, abnormal nasal discharge
Trouble breathing through nose
Postnasal drip
Sinus pain or headache
Sinus infection
Nasal polyps
Deviated septum
Nosebleeds
Broken nose

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Allergic rhinitis (nasal allergy)
Vasomotor rhinitis
Other nasal or sinus problem
[03- ATO- Proxy]
Does your child currently smoke?
No
Yes
Don’t know
[03a- ATO- Proxy]
If yes, how many cigarettes per day?

[05- ATO- Proxy]
Does your child drink caffeinated beverages?
No
Yes
Don’t know
[06- ATO- Proxy]
How many hours did your child sleep last night?
(If you do not know, please enter 99)

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[07- ATO- Proxy]
Is your child taking the sleep aid Lunesta®?
No
Yes

[08- ATO- Proxy]
Is your child taking any medications that may interfere with his/her taste?
No
Yes
[09- ATO- Proxy]
Has your child been to the dentist in the last 48 hours?
No
Yes
Don't know
[10- ATO- Proxy]
Select ALL of the following statements that apply to your child now:
He/she has a normal sense of smell
His/her sense of smell is distorted, that is, things smell peculiar
He/she experiences a smell when nothing is there (phantom smell)
His/her sense of smell is heightened (hypersensitive)
His/her sense of smell is diminished (partial loss)
His/her sense of smell is absent (complete loss)
[11- ATO- Proxy]
Compared to others his/her age, how would you rate your child's sense of smell?

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Excellent
Good
Fair
Poor

[12- ATO- Proxy]
Has your child noticed any recent change in his/her ability to detect odors?
No change in his/her ability to detect odors
Slight decrease in his/her ability to detect odors
Moderate decrease in his/her ability to detect odors
Severe decrease in his/her ability to detect odors
[14-ATO-proxy]
How often does your child find it difficult to follow a conversation if there is background
noise, for example, when other people are talking, TV or radio is on, or children are playing?
Always
Usually
About half the time
Seldom
Never
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[15-ATO-proxy]
Has your child ever used assistive listening devices (ADLs) such as FM systems, closedcaptioned television, amplified telephone, relay services or a sign-language interpreter?
Yes
No
Don't know
[16-ATO-proxy]
In the past 12 months, has your child been bothered by ringing, roaring, or buzzing in
his/her ears?
Yes
No
Don't know

[16a-ATO-proxy]
How long has your child been bothered by this ringing, roaring, or buzzing in his/her ears
or head?
Less than 3 months
Three months to a year
One to four years
Five to nine years
Ten or more years
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[16b-ATO-proxy]
How much of a problem is this ringing, roaring, or buzzing in the ears or head to your
child?
No problem
A small problem
A moderate problem
A big problem
A very big problem
Don't know

[19-ATO-proxy]
Has your child had regular exposure to any of the following? Check all that apply.
Herbicides/Pesticides
Acid or welding fumes
Industrial solvents or cleaning products
Cigarette smoke
Metal dusts
Wood dusts
Formaldehyde
Glues or adhesives
Don't know

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[21-ATO-proxy]
In the last 12 months, has your child had pain or burning in his/her mouth or tongue that
was not due to mouth sores?
Yes
No
Don't know
[20-ATO-proxy]
During the past 12 months, how would rate your child's sense of taste for salty, sour, sweet,
or bitter things?
Excellent
Good
Fair
Poor
My child has lost his/her sense of taste
Don't know