The Ear Foundation Santa Barbara

PET SYMPTOM IMPROVEMENT QUESTIONNAIRE

NAME __________________________________________ DATE _____________

BOTTLE # _______________ Affected Ear: _____ Right _____ Left


VERY IMPORTANT: All of the following questions (except question A) pertain to your symptoms: after you have taken the medication, while you are on the medication, and before it wears off. Do your best to give an answer that represents “on average.”

Circle one:

A. How many doses did you take each day?

1     2     3     4     Other _____

B. How many drops/dose?

1     2     3     4     Other _____

C. What time(s) did you usually take the dose(s)?

8am   9am   10am   11am   Noon   1pm   6pm  

Other ___________   N/A

D. How long did it take for the drops to relieve your symptoms?

Immediately    30 seconds   1 minute   Other ___________    N/A

E. Once relieved, how long did this relief last?

1 hour  2 hours   3 hours   4 hours  5 hours  16 hours  

All Day   Other ______   N/A

F. At what point did your symptoms return after you took the drops?

1hour   Same day   Next day   1week   Other ______   N/A

G. How did the sensation of your breathing or voice being annoying or abnormally loud change?

0. Not applicable
1. Very much better
2. Much better
3. A little better
4. No different
5. A little worse
6. Much worse
7. Very much worse

H. How did the fullness sensation in your ears change?

0. Not applicable
1. Very much better
2. Much better
3. A little better
4. No different
5. A little worse
6. Much worse
7. Very much worse

I. How did the crackling sound in your ears change?

0. Not applicable
1. Very much better
2. Much better
3. A little better
4. No different
5. A little worse
6. Much worse
7. Very much worse

J. How did your sense of general well being change?

0. Not applicable
1. Very much better
2. Much better
3. A little better
4. No different
5. A little worse
6. Much worse
7. Very much worse

K. How often did you experience:

1. The sensation of your breathing or voice being annoying or abnormally loud?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

2. A sensation of fullness or feel stopped up especially when you yawn or swallow?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

3. A crackling sound when gently blowing your nose or saying "m" or "n" sounds?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

L. To what extent did any of the previous 3 symptoms bother or annoy you?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

M. To what extent did these symptoms disable you?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

N. To what extent did these symptoms impair your concentration or memory of details?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

O. To what extent did these symptoms make you anxious, nervous or tense?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

P. To what extent did these symptoms decrease your enjoyment of life?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

Q. To what extent did these symptoms reduce your social activities?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

Please return copies of all forms to:

The Ear Foundation
2420 Castillo St, Suite 100
Santa Barbara CA, 93105-4346
Tel: (805) 569-1111
Fax: (805) 563-2277
E-mail: earfdn@aol.com