Does exposure to secondhand smoke affect central auditory function in young adults?
Department of Speech Pathology and Audiology- University of South Alabama
Dr. Ishara Ramkissoon, Ph.D., CCC-A
EMAIL: eplab1093@gmail.com
251-445-9393
--------------------------------------------------------------------------------------------------------------------------------Telephone Number
Name
Email
Address
Date of Birth: Month
Day
Year
1) Do you have any of the following health problems?
Mental illness
NO
Neurological Disease
NO
Alcohol dependency
NO
Chronic Cough
NO
Emphysema
NO
Asthma
NO
How old are you?
Gender:
(years)
Male
Female
YES
YES
YES
YES
YES
YES
2) Do you currently take any prescribed drugs or medications?
NO
YES
3) Do you currently use any non-prescribed drugs?
NO
YES
If yes, name them and state purpose:
4) If female, when was the first day of your last menstrual period?
5) Do you have any hearing or communication difficulties?
Month
Day
Year
If yes, please give more details:
NO
YES
NO
YES
NO
YES
NO
YES
6) Describe your cigarette smoking behavior:
Never smoked (nonsmoker)
Past Smoker------------Was this within the past 3 months?
Current Smoker
7) Have you used other tobacco products (E-cig, hookah, chew, pipe) in the past 3 months?
8) Do you live in a home in which one or more people smoke tobacco products?
9) If yes, how many people smoke inside your home?
1-2
10) About how many cigarettes per day are smoked inside your home?
3-4
1-4
5-9
5+
10-19
20+
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Does exposure to secondhand smoke affect central auditory function in young adults?
Department of Speech Pathology and Audiology- University of South Alabama
Dr. Ishara Ramkissoon, Ph.D., CCC-A
EMAIL: eplab1093@gmail.com
251-445-9393
--------------------------------------------------------------------------------------------------------------------------------11) Does any household member smoke outside but nearby the home (porch/patio)?
NO
12) If yes, how often are you directly exposed to this tobacco smoke per week, as it is directly given off?
Less than 1 hr
1-2 hrs
2-4 hrs
YES
4+ hrs
13) At work or school, how often are you exposed to tobacco smoke?
0-1 hr.
14) At work or school, if you smell smoke, how many people are smoking nearby?
1-4 hours
4+ hrs.
15) How many hours a week are you exposed to tobacco smoke in social or recreation settings (clubs, bars,
restaurants, sports, etc.)?
Less than 1 hr.
1-2 hrs.
2-4 hrs.
4-10 hrs.
10+ hrs.
16) When was the last time you were exposed to environmental tobacco smoke from any source?
Less than 12 hours ago
12-24 hours ago
17) Have you been exposed to very loud noises on a regular basis:
18) If yes, how many hours a week are you exposed to loud noises?
Less than 1
2-4
5-7
2 days ago
NO
8-10
19) In what environment or situations are you exposed to loud noises?
Personal Music Player
Bars/Clubs
Work
20) When was your most recent exposure to loud noise?
Home
Past Week
21) Do you experience Tinnitus (noises in your ear like ringing or buzzing)?
22) If yes, in which ear you hear the noise:
23) How often you hear these noises:
24) How long does the noise last for:
Daily
<1 min
Right
3 +days
10+
School
Past Month
Left
Occasionally
2-3 min
25) Have you ever had any prolonged exposure to:
YES
Car
NO
Hunting
3+ months
YES
Both
After noise exposure
Constantly
a. Chemicals, cleaning fluids or solvents:
NO
YES
c. Plastic or resin fumes:
NO
YES
b. Insect or plant spray:
26) Are you:
left-handed
NO
right-handed
YES
mixed handed?
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