Appendix B.

Interview with the child (performed in Portuguese).

Date:__/__/____ Register #_____________

Name: ______________________________ Age:_______________

School: ______________________________ Grade:_____________

1) Do you always understand what people say to you?

( ) Yes ( ) Sometimes it is difficult ( ) It is always difficult ( ) I don't know

2) Do you hear any kind of noise in your ears or head?

( ) Yes. Description:____________________ ( ) No ( ) I don't know

3) Are you bothered by it?

( ) Not at all ( ) A little ( ) A lot

4) Are you bothered by any sound?

( ) Yes. Description: ____________________( ) No ( ) I don't know

5) Have you ever done any of these:

( ) Gone to carnival parties

( ) Gone to shows or parties with very loud music (you have to yell to be heard)

( ) Played with fireworks or were close (6 feet) to someone playing with them

( ) Join an adult in a noisy job (woodwork, car repair facility, factories)

( ) Been in noisy vehicles (quadricycles, jet sky, kart, tractor)

( ) Listened to loud music at home or in the car. Who put it on?

( ) Listened to loud music using headphones or ear buds. Who put it on?

6) Have you ever had your hearing tested? Describe it.