LOUD SOUNDS SURVEY

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ABOUT YOU...

1. YOUR AGE:

2. MALE   FEMALE

3. YOUR EDUCATION:

In middle- or high- school now	Finished high school
1-4 years of college	Post-graduate work or degree(s)

ABOUT YOUR EXPOSURE TO LOUD SOUND...

4. WHAT IS THE SINGLE MOST MAJOR SOURCE OF LOUD SOUND/NOISE IN YOUR LIFE?

Music	Music—headphones	Hunting or shooting
Power tools	Street noise	Power boats or jetskis
Car racing	Heavy machinery	Motorcycles
If none of the above, please write in your major source of loud sound here:

4a. Do you have more than one significant source of loud sound in your life? If so, please list the secondary source(s) here.

Music	Music—headphones	Hunting or shooting
Power tools	Street noise	Power boats or jetskis
Car racing	Heavy machinery	Motorcycles
If your secondary loud sound source(s) is not listed, please write it in:

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 SOUND—WITHOUT A QUIET BREAK:

Less than 1/2 hour at a time	1/2 to one hour at a time
One to two hours at a time	Two to four hours at a time
Four to six hours at a time	Six to eight hours at a time, or more

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
Please check one of the six buttons above. If you wish to describe the feeling in more detail, use this space as well:

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.

The sound makes conversation slightly more difficult than in a quiet environment.

The sound makes conversation much more difficult, compared to a quiet environment.

The sound makes conversation extremely difficult—except short, shouted commands and questions.

The sound makes conversation impossible.

10. PLEASE RATE THE EFFORT REQUIRED FOR CONVERSATION IN THE PRESENCE OF THE LOUD SOUND, COMPARED TO CONVERSATIONAL EFFORT IN QUIET.

Same as in quiet	1.5 times as much effort	Twice as much effort
2.5 times as much effort	3 times as much effort	3.5 times as much effort
4 times as much effort	5 times as much effort	10 times as much effort

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?

Rarely or never	A few times per year
About once a month	More than once a month

12. DO YOUR EARS HURT AFTER EXPOSURE TO LOUD SOUND?

Rarely or never	A few times per year
About once a month	More than once a month

13. HAS YOUR HEARING DECREASED AS A RESULT OF EXPOSURE TO LOUD SOUND?

I am sure it has decreased	I am sure it has not changed
I think it has decreased	I think it has not changed

14. DO YOU WEAR EARPLUGS OR OTHER HEARING PROTECTION WHEN YOU ARE EXPOSED TO LOUD SOUND?

Rarely or never	Sometimes
Usually	Always

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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