ABOUT YOU...
1. YOUR AGE: 2. MALE FEMALE
3. YOUR EDUCATION:
ABOUT YOUR EXPOSURE TO LOUD SOUND...
4. WHAT IS THE SINGLE MOST MAJOR SOURCE OF LOUD SOUND/NOISE IN YOUR LIFE?
4a. Do you have more than one significant source of loud sound in your life? If so, please list the secondary source(s) here.
5. YOUR EXPOSURE TO LOUD SOUND/NOISE IS FROM: Work Leisure Both
6. YOUR EXPOSURE TO LOUD SOUND/NOISE IS: Every day Almost every day Occasional (varies greatly)
7. APPROXIMATE AMOUNT OF CONTINUOUS EXPOSURE TO LOUD SOUNDWITHOUT A QUIET BREAK:
ABOUT YOUR MAJOR SOURCE OF LOUD SOUND...
8. PLEASE DESCRIBE THE FEELING YOU GET FROM THE SOUND YOU LISTED AS YOUR MAJOR SOURCE OF LOUD SOUND (QUESTION 4):
Great!
Good
Indifferent (neutral)
Bad
Terrible!
It varies: sometimes it's good, sometimes it's bad
NOW: PLEASE IMAGINE TALKING WITH SOMEONE IN THE PRESENCE OF YOUR MAJOR LOUD SOUND.
9. PLEASE SELECT THE BEST DESCRIPTION OF THE EFFORT REQUIRED FOR CONVERSATION IN THE PRESENCE OF THE LOUD SOUND.
Conversation is the same as in a quiet environment.
10. PLEASE RATE THE EFFORT REQUIRED FOR CONVERSATION IN THE PRESENCE OF THE LOUD SOUND, COMPARED TO CONVERSATIONAL EFFORT IN QUIET.
ABOUT YOUR HEARING...
11. DO YOU EXPERIENCE TINNITUS (ROARING, RINGING, BUZZING, HISSING, MUFFLED SOUND, OR HIGH-PITCHED NOISE IN EARS) AFTER EXPOSURE TO LOUD SOUND?
12. DO YOUR EARS HURT AFTER EXPOSURE TO LOUD SOUND?
13. HAS YOUR HEARING DECREASED AS A RESULT OF EXPOSURE TO LOUD SOUND?
14. DO YOU WEAR EARPLUGS OR OTHER HEARING PROTECTION WHEN YOU ARE EXPOSED TO LOUD SOUND?
15. DO YOU BELIEVE LOUD SOUND CAN DAMAGE YOUR HEARING PERMANENTLY? Yes No I am not sure
16. OTHER COMMENTS ABOUT LOUD SOUND OR NOISE, OR ABOUT THIS FORM?
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