Audiometry
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?
When began to have hearing loss?
Cause of hearing loss-Genetic/Hereditary
Cause of hearing loss-Ear infections
Cause of hearing loss-Ear diseases
Cause of hearing loss-Illness/Infections
Cause of hearing loss-Drugs/Medications
Cause of hearing loss-Head/Neck injury
Cause of hearing loss-Loud brief noise
Cause of hearing loss-Long-term noise
Cause of hearing loss-Aging
Cause of hearing loss-Others
Ever used assistive listening devices?
Ever had ear infections or earaches?
Ever had 3 or more ear infections?
Ever had tube placed in ear?
Last time hearing tested by specialist?
Now use hearing aid/ amplifier/ implant
Now use a hearing aid
Now use a personal sound amplifier
Now have a cochlear implant
Past 2 weeks how often worn hearing aid
Ever worn hearing aid/amplifier/implant
Ever had Special Ed/Early Intervention
Had service for speech-language
Had service for reading
Had service for hearing/listening skills
Had service for intellectual disability
Had service for movement/mobility issues
Had service for other disabilities
Exposed to very loud noise 10+ hrs/wk
How long exposed to loud noise 10+hrs/wk
Difficult to follow conversation w/noise
Hearing causes frustration when talking?
Avoid groups, limit social life?
Problem with dizziness, lightheadedness?
Ears ringing, buzzing past year?
How long bothered by ringing, buzzing?
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?
Discussed ringing with doctor?
Ever used firearms for any reason?
How many total rounds ever fired?
Wear hearing protection when shooting?
Ever had 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?