Attachment 2e. Topical Module on
Hearing Problems
(Questions)
Topical Module on Hearing Problems (Questions)
These next questions are about your hearing WITHOUT the use of hearing aids or other assistive listening devices:
Is your hearing excellent, good, a little trouble hearing, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1 [Go To #15.]
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
2. Is your hearing WORSE in one ear than the other?
YES……………………………………………………………………………………………………………………………1 [Go to #2a]
NO…………………………………………………………………………………………………………………………….2 [Go to #5]
REFUSED 7
DON’T KNOW 9
2a. Which ear is worse?
THE RIGHT EAR 1
THE LEFT EAR 2
REFUSED 7
DON'T KNOW 9
3. Is your hearing in your RIGHT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
4. Is your hearing in your LEFT ear excellent, good, a little trouble, moderate trouble, a lot of trouble, or are you deaf?
EXCELLENT 1
GOOD 2
A LITTLE TROUBLE 3
MODERATE HEARING TROUBLE 4
A LOT OF TROUBLE 5
DEAF 6
REFUSED 7
DON’T KNOW 9
↔ 5. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person WHISPERS to you from across a quiet room?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
6. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person TALKS IN A NORMAL VOICE to you from across a quiet room?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
7. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SHOUTS to you from across a quiet room?
YES 1 [Go To #9.]
NO 2
REFUSED 7
DON’T KNOW 9
8. Can you usually HEAR AND UNDERSTAND what a person says without seeing his face if that person SPEAKS LOUDLY into your better ear?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
9. 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? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
10. How often does your hearing cause you to feel frustrated when talking to members of your family or to friends? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
11. How often does your hearing cause you to worry about your safety while working or doing other activities? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
IF GOOD HEARING TO QUESTION 1, AND HEAR THE SAME IN BOTH EARS,
SKIP TO Q15
12. How old were you when you began to have ANY permanent hearing loss (in either ear)?
AT BIRTH 1
0 TO 2 YEARS OF AGE 2
3 TO 5 YEARS OF AGE 3
6 TO 11 YEARS OF AGE 4
12 TO 19 YEARS OF AGE 5
20 TO 39 YEARS OF AGE 6
40 TO 59 YEARS OF AGE 7
60 TO 69 YEARS OF AGE 8
70 OR MORE YEARS OF AGE 9
REFUSED 97
DON’T KNOW 99
13. Was your hearing loss sudden or gradual?
*Read if necessary: Sudden means less than 3 months.
SUDDEN 1
GRADUAL 2
REFUSED 7
DON’T KNOW 9
14. What was the MAIN cause of your hearing loss?
PRESENT AT BIRTH BECAUSE MOTHER HAD GERMAN MEASLES (RUBELLA)
OR CYTOMEGALOVIRUS (CMV) 1
PRESENT AT BIRTH FOR A GENETIC REASON 2
PRESENT AT BIRTH FOR SOME OTHER REASON, NOT INCLUDING
GENETIC OR INFECTIOUS DISEASE 3
INFECTIOUS DISEASE AFTER BIRTH (MEASLES, MENINGITIS, ETC.)……. 4
EAR INFECTIONS OR OTITIS MEDIA 5
EAR INJURY (HOLES IN EARDRUM, ETC.) 6
EAR SURGERY 7
EAR DISEASES, SUCH AS MENIERE’S DISEASE OR OTOSCLEROSIS 8
BRAIN TUMOR (ACOUSTIC NEUROMA, ETC.)………………………………………………… 9
LOUD, BRIEF NOISE FROM GUNFIRE/BLASTS/EXPLOSIONS 10
NOISE EXPOSURE FROM MACHINERY, AIRCRAFT, POWER TOOLS, LOUD MUSIC,
APPLIANCES, PERSONAL STEREOS OR MP3 PLAYERS, HAIR DRYERS, ETC.. 11
GETTING OLDER/AGING 12
OTHER 13
REFUSED 97
DON’T KNOW 99
↔ 15. Have any of your friends or relatives ever told you that you have a hearing problem?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
16. When was the LAST time you saw a doctor or other health care professional about any hearing or ear problems?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO 3
5 TO 9 YEARS AGO 4 [GO TO #18.]
10 TO 14 YEARS AGO 5 [GO TO #18.]
15 OR MORE YEARS AGO 6 [GO TO #18.]
NEVER 7 [GO TO #18.]
REFUSED 97
DON’T KNOW 99
17a.In the past 5 years, were you ever referred by your doctor or other health care professional to a…
…hearing specialist, such as an Ear, Nose, and Throat doctor?
*Read if necessary: Include an Otolaryngologist or Otologist]
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW 9
17b. (Read lead-in if necessary):
…an audiologist or hearing aid dispenser?
YES…………………………………………………………………………………………………………………… 1
NO 2
REFUSED 7
DON'T KNOW…………………………………………………………………………………………………… 9
↔ 18. When was the last time you had your hearing tested?
IN THE PAST YEAR 1
1 TO 2 YEARS AGO 2
3 TO 4 YEARS AGO …………………………………………………………………………………………. 3
5 TO 9 YEARS AGO 4
10 TO 14 YEARS AGO 5
15 OR MORE YEARS AGO ……………………………………………………………………………….. 6
NEVER 7
REFUSED 97
DON’T KNOW 99
19. Do you now use a cochlear implant?
YES 1 [GO TO 20]
NO . 2 [GO TO 19A]
REFUSED 7 [GO TO 19A]
DON'T KNOW 9 [GO TO 19A]
19a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a cochlear implant to you?
YES…………………………………………………………………………………………………………………… 1 [ALL GO TO 20]
NO 2
REFUSED 7
DON'T KNOW 9
20. Do you now use a hearing aid?
YES 1 [GO TO 21]
NO . 2 [GO TO 23]
REFUSED 7 [GO TO 23]
DON'T KNOW 9 [GO TO 23]
21. How long have you worn a hearing aid(s)?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 97
DON’T KNOW 99
22. In the past 12 months, how often did you use a hearing aid? Would you say…
ALWAYS 1 [GO TO #27.]
USUALLY 2 [GO TO #27.]
ABOUT HALF THE TIME 3 [GO TO #27.]
SELDOM 4 [GO TO #27.]
NEVER 5 [GO TO #26]
REFUSED 7
DON'T KNOW 9
↔ 23. Have you ever used a hearing aid in the past?
YES 1 [GO TO 24]
NO 2 [GO TO #23A]
REFUSED 7 [GOTO #23A]
DON'T KNOW 9 [GOTO #23A]
23a. Has a hearing specialist, your doctor, or other health care professional ever recommended…
…a hearing aid to you?
YES…………………………………………………………………………………………………………………… 1 [GO TO 26]
NO 2 [GO TO 27]
REFUSED 7 [GO TO 27]
DON'T KNOW 9 [GO TO 27]
24. How long did you use a hearing aid(s) in the past?
LESS THAN 6 WEEKS …………………………………………………………………………………….. 1
6 WEEKS TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS …………………………………………………………………………………………. 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 OR MORE YEARS ……………………………………………………………………………….. 7
REFUSED 77
DON’T KNOW 99
25. During this time, how often did you use a hearing aid(s) Would you say…?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
26. Why have you decided not to use a hearing aid? [Mark all that apply.]
IT DIDN’T HELP 1
DIDN’T LIKE THE WAY IT SOUNDED/TOO LOUD/NOISY ..………………………….2
WHISTLING SOUNDS 3
IT WAS UNCOMFORTABLE 4
IT HAD FREQUENT BREAKDOWNS/NEEDED REPAIRS 5
DIDN’T LIKE THE WAY IT LOOKED 6
IT COST TOO MUCH 7
DON’T THINK I NEED A HEARING AID……………………………………………….…………8
OTHER …………………………………………………………………………………………..………………9
REFUSED 97
DON'T KNOW 99
If Hearing is Excellent, skip 27, 28 or if hearing is Good and hear the same in both ears skip 27, 28; else go to 27↔
27. Because of your hearing, have you ever used assistive listening devices (ALDs), such as FM systems, closed-captioned television, or amplified telephone or relay services?
YES 1
NO 2 [Go To #29.]
REFUSED 7
DON’T KNOW 9
28. Which of the following assistive listening devices have you ever used?
FR: SHOW FLASHCARD [MARK ALL THAT APPLY.]
POCKET TALKER OR OTHER PERSONAL LISTENING DEVICE……………………….. 1
AMPLIFIED TELEPHONE…………………………………………………………………………………… 2
AMPLIFIED OR VIBRATING ALARM CLOCK……………………………………………………… 3
NOTIFICATION OR SIGNALING SYSTEM (LIGHT SIGNALER FOR DOORBELL,
BABY CRY MONITOR, ETC.)……………………………………………………………………. 4
TELEVISON/THEATER HEADSET OR CLOSED CAPTIONED TV…………………………… 5
TTY (TELETYPEWRITER), TDD (TELECOMMUNICATIONS DEVICE FOR THE DEAF), OR TELEPHONE RELAY SERVICE ……………………………………………… 6
VIDEO RELAY SERVICE …………………………………………………………………………………… 7
SIGN LANGUAGE INTERPRETER...................................................... 8
OTHER 9
REFUSED 97
DON'T KNOW…………………………………………………………………………………………………… 99
↔ 29. In the past 12 months, have you been bothered by ringing, roaring, or buzzing in your ears or head that lasts for 5 minutes or more?
*Help screen: Definition of tinnitus as ringing, roaring, or buzzing.
YES 1
NO 2 [Go To #36.]
REFUSED 7
DON'T KNOW 9
30. How long have you been bothered by this ringing, roaring, or buzzing in your ears or head?
LESS THAN 3 MONTHS 1
3 TO 11 MONTHS 2
1 TO 2 YEARS 3
3 TO 4 YEARS 4
5 TO 9 YEARS 5
10 TO 14 YEARS 6
15 YEARS OR MORE 7
REFUSED 97
DON’T KNOW 99
31. In the past 12 months, how often have you had this ringing, roaring, or buzzing in your ears or head? Would you say…
ALMOST ALWAYS 1
AT LEAST ONCE A DAY 2
AT LEAST ONCE A WEEK 3
AT LEAST ONCE A MONTH 4
LESS FREQUENTLY THAN ONCE A MONTH 5
REFUSED 7
DON’T KNOW 9
32. Are you bothered by ringing, roaring, or buzzing in your ears or head only after listening to loud sounds or loud music?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
33. Are you bothered by ringing, roaring, or buzzing in your ears or head when going to sleep?
YES 1
NO 2
REFUSED 7
DON'T KNOW 9
34. How much of a problem is this ringing, roaring, or buzzing in your ears or head? Would you say it is…
NO PROBLEM 1
A SMALL PROBLEM 2
A MODERATE PROBLEM 3
A BIG PROBLEM 4
A VERY BIG PROBLEM 5
REFUSED 7
DON’T KNOW 9
35. Have you ever discussed this ringing, roaring or buzzing in your ears or head with your doctor or other health care professional?
YES 1 [Go To 35a]
NO 2 [Go To 36]
REFUSED 7 [Go To 36]
DON'T KNOW 9 [Go to 36]
35a. Have you ever tried any remedies or treatments for
the ringing, roaring, or buzzing in your ears or head?
YES…………………………………………………………………………………………… 1 [Go To 35b]
NO……………………………………………………………………………………………. 2 [Go To 36]
REFUSED…………………………………………………………………………………. 3 [Go To 36]
DON’T KNOW…………………………………………………………………………… 4 [Go To 36]
35b. Which of the following treatments have you tried? [SHOW FLASHCARD] [ENTER ALL THAT APPLY]
AMPLIFICATION/HEARING AIDS………..……………………………………… 1
MASKING WITH WEARABLE DEVICE (WITH OR WITHOUT
HEARING AIDS)……………………………………………..………..………………. 2
MASKING WITH NON-WEARABLE DEVICE (SOUND
GENERATORS TO HELP WITH SLEEP)…………………………..…………… 3
COGNITIVE THERAPY WITH COUNSELING………………………………… 4
STRESS REDUCTION OR RELAXATION METHODS………….…………. 5
BIOFEEDBACK…………………………………………………………………………….. 6
TINNITUS RETRAINING THERAPY (TRT)………….………………………… 7
PSYCHIATRIC TREATMENT………………………….……………………………… 8
SURGERY TO CUT THE HEARING NERVE…………………………………… 9
DRUGS OR MEDICATIONS…………………………………………………………. 10
NUTRITIONAL SUPPLEMENTS………………………..………………………….. 11
MUSIC THERAPY………………….……………………………………………………… 12
TEMPORAL MANDIBULAR JOINT TREATMENT………….………………… 13
ALTERNATIVE METHODS/HYPNOSIS, ACUPUNCTURE…….…….... 14
OTHER………………………………………………………………………………………… 15
REFUSED……………………………………………… ………………………………….. 97
DON’T KNOW………………………………………………… …………………………. 99
THE NEXT FEW QUESTIONS ARE ABOUT YOUR CURRENT OR PREVIOUS EXPOSURE TO LOUD
SOUNDS OR NOISES.
↔
36. Have you ever used firearms for any reason?
*Read if necessary: Include target shooting, hunting, your job including military service.
* Read if necessary: Firearms include pistols, shotguns, rifles, and other type of guns. Do not include BB or pellet guns.
YES 1
NO 2 [GO TO #40.]
REFUSED 7
DON'T KNOW 9
36a. Was this for work, leisure, or both?
WORK……………………………………………………………………………………………….………… 1
LEISURE…………………………………………………………………………………………….………. 2
BOTH WORK AND LEISURE………………………………………………………..…………….. 3
REFUSED 7
DON'T KNOW 9
37. How many TOTAL rounds have you ever fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 TO LESS THAN 50,000………………………………………………………………………. 4
50,000 ROUNDS OR MORE………………………………………………………………………… … 5
REFUSED 7
DON'T KNOW 9
38. In the past 12 months, about how many rounds have you fired?
*Read if necessary: Include target shooting, hunting, your job, including military service
*One round equals one shot.
NONE 0 [GO TO #40]
1 TO LESS THAN 100 ROUNDS 1
100 TO LESS THAN 1000 ROUNDS 2
1000 TO LESS THAN 10,000 ROUNDS 3
10,000 ROUNDS OR MORE 4
REFUSED 7
DON'T KNOW 9
39. In the past 12 months, when shooting firearms how often have you worn ear plugs or ear muffs? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
↔ 40. Have you ever had a job, or combination of jobs, where you were exposed to loud sounds or noise 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 1 [Go To #40a]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON'T KNOW 9 [Go To #44]
40a. For how many months or years have you been exposed at work to loud sounds or noise for 4 or more hours a day, several days a week?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
LESS THAN 3 MONTHS 1
3 MONTHS TO 11 MONTHS 2
1 TO 4 YEARS 3
5 TO 9 YEARS 4
10 TO 14 YEARS 5
15 YEARS OR MORE 6
REFUSED 7
DON’T KNOW 9
41. Was this in the past 12 months?
YES 1 [Go To #42]
NO 2 [Go To #44.]
REFUSED 7 [Go To #44]
DON’T KNOW 9 [Go To #44]
42. In the past 12 months, how often did you wear ear plugs or ear muffs when exposed to loud sounds or noise at work? Would you say…
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
44. Outside of work, have you ever been exposed to loud sounds or noise 10 or more times a year? This includes noise from power tools, loud music, racing or speedways, household appliances, or other things?
*Read if necessary: Loud means so loud that you must speak in a raised voice to be heard.
YES 1
NO 2 [Go To END]
REFUSED 7
DON’T KNOW 9
45. Which of the following activities have you been ever been exposed to 10 or more times for a year?
FR: SHOW FLASHCARD [Mark all that apply.]
MOTORCYCLES/AUTO RACING/SNOWMOBILE/MOTOR BOAT………………………… 1
OPERATING FARM MACHINERY 2
WOOD CUTTING, WOODWORKING, OR OTHER WORKSHOP POWER TOOLS 3
USING LAWN MOWER/ELECTRIC TRIMMER/LEAF/SNOW BLOWER 4
FIREARMS………………………………………………………………………………………………………… 5
HOUSEHOLD APPLIANCES: BLENDER/MIXER, FOOD PROCESSOR,
VACUUM CLEANER, HAIR DRYER, ETC.………………………………. 6
MP3 PLAYER/iPOD……………………………………………………………………………………………. 7
PLAYING IN A MUSIC GROUP………………………………………………………………………….. 8
OTHER MUSIC RELATED ACTIVITIES: ROCK CONCERTS/STEREOS/
DISCO/CLUBS OR BARS 9
OTHER NOISY, NON-WORK-RELATED ACTIVITIES……………………………………….. 10
REFUSED 97
DON'T KNOW 99
46. Was this in the past 12 months?
YES 1
NO 2 [Go To END.]
REFUSED 7
DON'T KNOW 9
47. In the past 12 months, when exposed to loud noise or music outside of work, how often have you worn ear plugs or ear muffs?
ALWAYS 1
USUALLY 2
ABOUT HALF THE TIME 3
SELDOM 4
NEVER 5
REFUSED 7
DON'T KNOW 9
| File Type | application/msword |
| File Title | Attachment 2a |
| Author | hcr8 |
| Last Modified By | CBarksdale |
| File Modified | 2006-12-15 |
| File Created | 2006-12-15 |