ASSESSMENT QUESTIONAIRE FOR ADULTS 8. Did you have hearing loss during or after this disease?

a) No ( ) b) Yes ( ) c) I do not know ( ) d) It doesn’t apply ( )

Name:__________________________________________________________
9. Did you have any illness that led you to lose hearing?
Age:__________________ Date of birth:______________________________ a) No ( ) b) Yes ( ) c) I do not know ( )

Profession: ___________________ Telephone:_________________________ 10.Have you ever had a cold or sinusitis in the past 4 weeks?
a) No ( ) b) Yes ( ) c) I do not know ( )
HEARING
11. Have you ever suffered a hit in the head that left you unconscious?
1. In your opinion your hearing is: a) No ( ) b) Yes ( ) c) I do not know ( )
Good RE ( ) LE ( ) When? ___________________________
Normal RE ( ) LE ( )
Bad RE ( ) LE ( ) 12. Do you remember being close to an explosion or loud noise that
Since when? ___________________________ caused you pain in the ear, hearing loss or ringing?
a) No ( )
2. Have you used hearing aids? b) Yes, in both ears ( )
No ( ) c) Yes, only in the RE ( )
Yes ( ) in which ear? _______________ for how long? ___________________ c) Yes, only in the LE ( )
e) Yes, I am not able to tell which side ( )
3. Did you have infections or ear pain as a child? f) I do not remember ( )
2.1 No ( ) Yes ( ) I do not know ( ) When? ___________________________

4. What was the frequency of such episodes? 13. Have you ever been subjected to ear surgery?
a) Less than 1 per year ( ) a) No ( )
b) 1 per year ( ) b) Yes, bilaterally ( )
c) More than 1 per year ( ) c) Yes, RE ( )
d) I do not know ( ) d) Yes, LE ( )
e) Does not apply ( ) e) Yes, I am not able to tell which side ( )
f) I do not remember ( )
5. Do you often have infections or ear pain now as an adult? When? ___________________________
3.1 No ( ) Yes ( ) I do not know ( )
14. Does any member of your family have hearing impairment?
6. What was the frequency of such episodes? a) None ( )
a) Less than 1 per year ( ) b) Only one of the parents ( )
b) 1 per year ( ) c) Both parents ( )
c) More than 1 per year ( ) d) Brother/sister ( )
d) I do not know ( ) e) Grandparents ( )
e) It does not apply ( ) f) I do not know ( )

7. Have you ever had any of these diseases? 15. Do you feel some ringing in the ears?
a) Measles ( ) a) Never ( ) b) Sometimes ( ) c) Always ( )
b) High pressure ( )
c) Tuberculosis ( )
d) Diabetes ( )
e) Mumps ( )
f) No ( )
16. What is the location? Other_____________ ( )
a) Bilateral ( )
b) RE ( ) 22. How do you consider the intensity of noise exposure to which you are currently
c) LE ( ) exposed in the workplace?
d) I do not know ( ) a) Zero ( )
e) It does not apply ( ) b) Mild ( )
c) Moderate ( )
17. Have you ever taken some remedy that you have perceived it has affected your d) Intense ( )
hearing or that caused ringing in your ears?
a) No ( ) 23. Do you use hearing protector?
b) Yes, hearing loss ( ) a) No ( ) b) Yes ( ) Type_____________________________________
c) Yes, ringing ( )
d) Yes, both ( ) NON-OCCUPATIONAL NOISE EXPOSURE
e) I do not know ( )
24. Have you ever used a firearm?
18. Do you smoke? a) No ( )
a) No ( ) b) Yes ( ) b) Yes /without hearing protector ( )
c) Yes /with a hearing protector ( )
OCCUPATIONAL HISTORY
25. For how long?
19. Have you ever worked or you currently work in very noisy environments? a) It does not apply ( )
a) No ( ) b) Yes ( ) b) 3 years or less ( )
c) 4 to 10 years ( )
20. History of occupational noise exposure d) 10 years or more ( )
- Company:__________________________________________________
- Position:___________________________________________________ 26. How often?
- Total weekly hours of noise exposure:___________________________ a) It does not apply ( )
- Total years of noise exposure:_________________________________ b) Rarely ( )
- Did you use hearing protection?: Yes ( ) No ( ) c) Sporadically ( )
d) Frequently ( )
- Company:_________________________________________________
- Position:__________________________________________________ 27. How often do you use a motorcycle?
- Total weekly hours of noise exposure:___________________________ a) No ( )
- Total years of noise exposure:_________________________________ b) Yes / with helmet ( )
- Did you use hearing protection?: No ( ) Yes ( ) c) Yes / without helmet ( )

21. Do you know if you were or you are currently exposed to the following chemical 28. Do you participate in any other activity involving bustling activity?
products? a) No ( ) b) Yes ( )

Toluene ( ) 29. If the answer is yes, what activity and how often?
Xylene ( ) _________________________________________________________________________
Styrene ( ) _________________________________________________________________________
Carbon disulfate ( ) _________________________________________________________________________
Etilbenzeno ( ) _________________________________________________________________________
Ethanol ( )
Hexane ( )
Mercury ( )
Carbon monoxide ( ) Thank you