4. Have you been exposed to loud noise or listened to music with headphone in the past 24 hours? [ ] Yes [ ] No [ ] Refused [ ] Don t know

Transcription

1 PhenX Measure: Audiogram Hearing Test (#200100) PhenX Protocol: Audiogram Hearing Test (#200101) Date of Interview/Examination (MM/DD/YYYY): Preliminary Activities 1. Does the examinee have hearing aids that cannot be removed? [ ] Yes Examinee skips the audiogram Pre-Exam Questionnaire 2. Do you now have a tube in your right or left ear [if Yes, indicate affected ear(s)]? [ ] Yes, right ear [ ] Yes, left ear [ ] Yes, both ears 3. Have you had a cold, sinus problem or earache in the last 24 hours? [ ] Yes 3.1. (If yes) Which have you had (check all that apply)? [ ] Cold [ ] Sinus problem [ ] Earache, right ear [ ] Earache, left ear [ ] Earache, both ears 4. Have you been exposed to loud noise or listened to music with headphone in the past 24 hours? [ ] Yes 4.1. (If Yes) How many hours ago did the noise or music end?

2 Number of hours (Enter response to the nearest hour; round up partial quantities of 30 minutes or more) 5. Do you hear better in one ear than the other? [ ] Yes, right ear [ ] Yes, left ear If a study participant reports better hearing in one ear than the other, air conduction testing should begin in that ear. Otoscopy 6. Enter a comment to describe the right ear rmal excludes any other result, except for collapsed canal [ ] Excessive cerumen precludes the use of insert earphone during audiometry [ ] Impacted cerumen [ ] Abnormality, type unknown (describe) [ ] Collapsing ear canal requires the use of insert earphones during audiometry 6.1. If answer is Abnormality, type unknown, enter a comment: 7. Enter a comment to describe the left ear rmal Excludes any other result, except for collapsed canal [ ] Excessive cerumen [ ] Impacted cerumen [ ] Abnormality, type unknown [ ] Collapsing ear canal requires the use of insert earphones during audiometry

3 7.1. If answer is Abnormality, type unknown, enter a comment: Acoustic Immitance 8. Right ear dapa [ ] 777 Could not obtain [ ] 888 SP refused 8.1. Right ear tympanogram ID: 9. Left ear dapa [ ] 777 Could not obtain [ ] 888 SP refused 9.1. Left ear tympanogram ID: Audiometry 10. Ear tested first [ ] Right ear [ ] Left ear 11. Could not obtain

4 [ ] Right ear [ ] Left ear 12. Headphones used (original test): [ ] Regular [ ] Insert 13. Test mode right ear [ ] Automatically [ ] Manually [ ] Mixed 13.1 If mixed, indicate Hz when switched to manual mode (Right Ear) [ ] 1000 First [ ] 500 [ ] 1000 Second [ ] 2000 [ ] 3000 [ ] 4000 [ ] 6000 [ ] Right ear 1000 Hz (first) threshold: Right ear 500 Hz threshold:

5 13.4. Right ear 1000 Hz (second) threshold: Right ear 2000 Hz threshold: Right ear 3000 Hz threshold: Right ear 4000 Hz threshold: Right ear 6000 Hz threshold: Right ear 8000 Hz threshold: 14. Test mode left ear [ ] Automatically [ ] Manually [ ] Mixed

6 14.1 If mixed, indicate Hz when switched to manual mode (Left ear) [ ] 1000 First [ ] 500 [ ] 1000 Second [ ] 2000 [ ] 3000 [ ] 4000 [ ] 6000 [ ] Left ear 1000 Hz (first) threshold: Left ear 500 Hz threshold: Left ear 1000 Hz (second) threshold: Left ear 2000 Hz threshold: Left ear 3000 Hz threshold:

7 14.7. Left ear 4000 Hz threshold: Left ear 6000 Hz threshold: Left ear 8000 Hz threshold: Retesting with insert headphones should be performed when testing with standard headphones results in a difference in threshold between the right and left ears at the same frequency of 25 db or more at 500 or 100 Hz, or 40 db or more at 2000 Hz or higher Right ear retest 1000 Hz (first) threshold: Right ear retest 500 Hz threshold: Right ear retest 1000 Hz (second) threshold: Right ear retest 2000 Hz threshold:

8 15.5. Right ear retest 3000 Hz threshold: Right ear retest 4000 Hz threshold: Right ear retest 6000 Hz threshold: Right ear retest 8000 Hz threshold: Left ear retest 1000 Hz (first) threshold: Left ear retest 500 Hz threshold: Left ear retest 1000 Hz (second) threshold: Left ear retest 2000 Hz threshold:

9 16.5. Left ear retest 3000 Hz threshold: Left ear retest 4000 Hz threshold: Left ear retest 6000 Hz threshold: Left ear retest 8000 Hz threshold: Protocol Source: