QUESTIONNAIRE

N˚

Question

Codification

Response

IDENTIFICATION

Identification Number

/__/__/__/__/

Date of registration

/__/__/./__/__/./__/__/__/__/

Full name of the investigator

………………………………………

SOCIO-DEMOGRAPHIC PARAMETERS

1

How old are you ?

/__/__/

2

Gender

Female = 0

Male = 1

/__/

BACKGROUND

3

Cranial trauma

No = 0

Yes = 1

/__/

4

Persistent or repeated otologic infections

No = 0

Yes = 1

/__/

5

Tumor

No = 0

Yes = 1

/__/

6

Otologic Surgery

No = 0

Yes = 1

7

Use of ototoxic medication

No = 0

Yes = 1

/__/

8

Other

…………………………………..

OCCUPATIONAL FACTORS AND NOISE EXPOSURE

9

Current battalion

1^stCamp Guézo Motorized Intervention Battalion = 0

Music Squadron = 1

/__/

10

What is your seniority in the army (year)

/__/__/

11

What is your seniority in the music squadron (year)

/__/__/

12

What musical instrument do you play?

String instruments = 0 ……

Percussion = 1 …………

Wind instruments = 2 ……

/__/

13

How many days per week do you practice music (professional practice)

/__/__/

14

How many hours do you practice music per day (professional practice)

/__/__/

15

Noise level of the working environment

/__/__/__/

BEHAVIOURAL FACTORS

16

Do you wear hearing protection?

No = 0

Yes = 1

/__/

17

Do you practice music extra-professionally?

No = 0

Yes = 1

/__/

MORBIDITES

18

Otorrhea

No = 0

Yes = 1

/__/

19

Otalgia

No = 0

Yes = 1

/__/

20

Tinnitus

No = 0

Yes = 1

/__/

21

Hearing loss

No = 0

Yes = 1

/__/

22

Other

……………………………

Audiometric Parameters

23

Average hearing loss in the right ear

/__/__/__/

24

Average hearing loss in the left ear

/__/__/__/

25

Type of hearing loss

Conductive = 0

Sensorineural = 1

Mixed = 2

/__/