Audiometry
Respondent sequence number
General condition of hearing
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
Last time hearing tested by specialist?
Difficult to follow conversation w/noise