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[p.45]


HEARING ABILITY SUPPLEMENTARY QUESTIONNAIRE
NATIONAL HEALTH SURVEY: (HEARING ABILITY)

Name of person for whom this form should be filled out: ________

General instructions:

Please answer all the questions in this form that apply to you. Most of the questions can be answered by checking one of the boxes, like this: [ ]. In some of the questions, more than one box may be checked for your answer. In a few questions, a number (such as age) is asked for. In a few others, a written description or explanation is required.
If the person for whom the information is requested is a child, a parent, or guardian should answer the questions for him or her

.

Section A
(Please do not omit any part of Questions 1 and 2 even though one or more of the statements may not appear to be directly related to your present ability to hear)

1. Without using a hearing aid, what can you hear?
(please check the "Yes" or "No" box after each statement)

I can hear loud noises
[] Yes
[] No
Most of the time I can tell one kind of noise from another
[] Yes
[] No
If I hear a sound, most of the time I can tell if it is a person's voice or not
[] Yes
[] No
I can hear and understand a few words a person says if I can see his face and lips
[] Yes
[] No
I can hear and understand a few words a persons says without seeing his face and lips
[] Yes
[] No
I can hear and understand most of the things a person says if I can see his face and lips
[] Yes
[] No
I can hear and understand most of the things a person says without seeing his face and lips
[] Yes
[] No
Most of the time I can hear and understand a discussion between several people without seeing their faces and lips
[] Yes
[] No
I can hear and understand a telephone conversion on an ordinary telephone (that is a telephone wihtout an amplifier)
[] Yes
[] No

2. Please describe how well you can hear, without using a hearing aid, by checking one of the statments below for each ear. For example, a person who is deaf in his left ear and has good hearing in his right ear would check the following: In left ear -box (d); in right ear-box (c).

[] In left ear
(a) [] my hearing is good
(b) [] I have little trouble hearing
(c) [] I have a lot of trouble hearing
(d) [] I am deaf
[] In right ear
(e) [] My hearing is good
(f) [] I have a little trouble hearing
(g) [] I have a lot of trouble hearing
(h) [] I am deaf

If you have checked that your hearing is good in both ears -- (a) and (e) checked, skip the questions on page 2 and 3 and turn to section D on page 4.
If you have any trouble hearing at all, please go on and answer the questions that follow on page 2 and 3

[p.46]

3. How old were you when you began to have hearing trouble or grow deaf?
(Please check the first box that applies and enter year as appropriate)

[] At birth
[] I was less than one year old
[] I was about ____ years old
[] I am not sure, but I know it was before I was ____ years old

4(a). Since your hearing trouble began, has your hearing gotten worse, has it improved, or is it just about the same? (Please check one box)

[] My hearing is now worse than when I first began to have hearing trouble
[] My hearing is now better than when I first began to have hearing trouble
[] My hearing is just about the same as when I first began to have hearing trouble
(if you have checked that you hearing has gotten worse, please answer the following question)

b. How old were you when it got as poor as it is now?
(please check the first box that applies and enter year as appropriate)

[] I was about ____ years old
[] I am not sure, but I know it was before I was ____ years old
[] Neither of the above applies-- it is getting worse all the time

.

5. What was the cause of your hearing trouble or deafness?

[] It was caused by a sickness, illness or disease.
What illness? ________
[] It was caused by an accident or injury

.

What kind of injury was it? ________
How did it happen?________
[] I was born deaf or with poor hearing
[] Something else caused it. (please describe it) ________
[] I don't know what caused it

.

6.Besides your hearing trouble or deafness, do you have any other trouble with your ear?

[] Yes
[] No
If "Yes"
What kind of trouble? (Please check as many boxes as apply)
[] Noises or ringing in the head or ear
[] Earaches or pains in the ear
[] Running ears
[] Dizziness
[] Any other trouble. What kind? ________

7. (a) At work or school and at home, what are all the ways you use to tell other people what you want?
(Please check each way that you use)

[] I talk to them
[] I write notes
[] I spell with my fingers
[] I use sign language
[] Some other way. How?________

b. Please put a circle around the way you use the most.

[] I talk to them
[] I write notes
[] I spell with my fingers
[] I use sign language
[] Some other way.

8. (a) At work or school and at home, what are all the ways other people use to tell you what you want? (please check each way that they use)

[] They talk to me
[] They write notes
[] They spell with their fingers
[] They use sign language
[] Some other way. How? ________

b. Please put a circle around the way they use the most.

[] They talk to me
[] They write notes
[] They spell with their fingers
[] They use sign language
[] Some other way.

9. Have you ever attended a school or class for those with poor hearing or a school or class for the deaf?

[] Yes
[] No

10. Have you ever had any training in lip reading (speech reading)?

[] Yes
[] No

11. Have you ever had any training in speech or speech correction because of your poor hearing or deafness?

[] Yes
[] No

12. Have you ever had any training in hearing (lessons to help you understand better what you hear)?

[] Yes
[] No

[p.47]

(the questions in this section refer to the use of hearing aids)
13. Have you ever tried a hearing aid?

[] Yes
[] No (if "No" skip to Section D on page 4)

14. Have you ever had a hearing aid for your own use?

[] Yes
[] No (if "No" skip to Section D on page 4)

15.(a) If you have a hearing aid now, please check here []
and check one of the boxes below to indicate when you got it.
If you do not have a hearing aid NOW, please check here []
and check one of the boxes below to indicate when you got the last one you had.
When did you get it?

[] This year (1962)
[] Last year (1961)
[] 2-5 years ago
[] 6-10 years ago
[] More than 10 years ago

The remaining parts of Question 15 apply to your present hearing aid if you have one new. If you do not have a hearing aid now, they apply to the last hearing aid you had.
b. what kind of hearing aid is (was) it?
(Please check one box)

[] Air conduction
[] Fits into one ear
[] Fits into both ears at the same time
[] Bone conduction
[] Fits against one side of the head
[] Fits against both sides of the head at the same time

c. Where are (were) the amplifier and batteries worn when you use (used) the hearing aid?
(please check one box)

[]Above the neck
[] Below the neck

d. Why did you choose this (that) particular kind of hearing aid?
(please check one box)

[] It was prescribed by a medical doctor
[] It was prescribed by a hearing clinic
[] A friend or relative told me about it
[] I saw it advertised
[] It was advised by a hearing aid dealer
[] Some other reason (please explain) ________

e. About how long did it take to get used to it? (please check one box)

[] Less than one month
[] One to six months
[] More than six months
[] Never have gotten used to it

16.(a) Do you use a hearing aid now?

[] Yes
[] No (if "No" skip to section D on page 4)

b. How much do you use it? (please check one box on each line)
(if you do not work, go to school etc., check the "does not apply" column)

At work?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never
At school?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never
At church?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never
At the movies?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never
Listening to radio or TV?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never

At home?
[] Does not apply
[] Most of the time
[] Once in a while
[] Never

c. How well satisfied are you with hearing aid you are now using?
(Please check one box)

[] Very well satisfied
[] Fairly well satisfied
[] Not satisfied at all

[p.48]

17. With your hearing aid, what can you hear? (please check the "Yes" or "No" box after each statement?

I can hear loud noises
[] Yes
[] No
Most of the time I can tell one kind of noise from another
[] Yes
[] No
If I hear a sound, most of the time I can tell if it is a person's voice or not
[] Yes
[] No
I can hear and understand a few words a person says if I can see his face and lips
[] Yes
[] No
I can hear and understand a few words a person says without seeing his face and lips
[] Yes
[] No
I can hear and understand most of the things a person says if I can see his face and lips
[] Yes
[] No
I can hear and understand most of the things a person says without seeing his face and lips
[] Yes
[] No
Most of the time I can hear and understand a discussion between several people without seeing their faces and lips
[] Yes
[] No
I can hear and understand a telephone conversion on any telephone
[] Yes
[] No

Section D

18. Has your hearing ever been tested by a medical doctor?

[] Yes
[] No (if "No" go to Question 19)

(a) About how long ago was your hearing LAST tested by a medical doctor? (Please check one box)

[] This year (1962)
[] Last year (1961)
[] 2-3 years ago
[] 4-5 years ago
[] 6-10 Years ago
[] More than 10 years ago

(b) Was the doctor who last tested your hearing an ear specialist or was he a general family doctor? (Please check one box)

[] Doctor who was an ear specialist
[] General family doctor
[] I don't know

(c) About how old were you when your hearing was first tested by a medical doctor?

I was about _____ years old
I don't know, but it was before I was _____ years old

19. Is your hearing tested regularly, for example, once or twice a year?

[] Yes
[] No

20. Has your hearing ever been tested with an audiometer (with earphones)?

[] Yes
[] No

Comments: (please use space or attach an additional sheet of paper for any additional remarks you may have about your hearing) ________________________

Name of person who filled out this form____________
Telephone No. _________