Respondent sequence number
General condition of hearing
Hear a whisper from across a quiet room?
Hear normal voice across a quiet room?
Hear a shout from across a quiet room?
Hear if spoken loudly to in better ear?
Difficult follow conversation if noise
Hearing cause frustration when talking?
Ever had 3 or more ear infections?
Ever had tube placed in ear?
Last time hearing tested by specialist?
Ever worn hearing aid/cochlear implant?
Hearing aid or Cochlear implant?
Past year how often worn hearing aid?
Ever used assistive listening devices?
Ears ringing, roaring, buzzing past year
How long bothered by ringing, roaring
In past yr how often had ringing/roaring
Bothered by ringing after loud sounds?
Bothered by ringing when going to sleep
How much of a problem is ringing?
Ever used firearms for any reason?
How many total rounds ever fired?
Wear hearing protection when shooting?
Ever had a job exposure to loud noise?
How long exposed to loud noise at work?
Ever exposed to very loud noise at work
How long exposed to very loud noise?
Had off-work exposure to loud noise?
Past year: worn hearing protection?