From: Clinimetric evaluation and clinical outcomes of the Dutch version of the Chronic Ear Survey
Activity Restriction Based-Subscale | ||||||
A1 | Because of your ear problem, you don’t swim or shower without protecting your ear. | |||||
Definitely true | True | False | Definitely false | |||
A2 | At the present time, how severe a limitation is the necessity to keep water out of your ears? | |||||
Very severe | Severe | Moderate | Mild | Very mild | None | |
A3 | In the past four weeks, has your ear problem interfered with your social activities with friends, family and groups? | |||||
All of the time | Most of the time | A good bit of the time | Some of the time | A little of the time | None of the time | |
Symptom scale | ||||||
S1 | Your hearing loss is: | |||||
Very severe | Severe | Moderate | Mild | Very mild | None | |
S2 | Drainage from your ear is: | |||||
Very severe | Severe | Moderate | Mild | Very mild | None | |
S3 | Pain from your ear is: | |||||
Very severe | Severe | Moderate | Mild | Very mild | None | |
S4 | Odor from your ear is very bothersome to you and/or others: | |||||
Definitely true | True | Don’t know | False | Definitely false | ||
S5 | The hearing loss in your affected ear bothers you: | |||||
All of the time | Most of the time | A good bit of the time | Some of the time | A little of the time | None of the time | |
S6 | In the past 6 months, please estimate the frequency that your affected ear has drained: | |||||
Constantly | 5 or more times, but not constantly | 3–4 times | 1–2 times | Not at all | ||
S7 | The odor from your ear affected ear bothers you and/or others: | |||||
All of the time | Most of the time | A good bit of the time | Some of the time | A little of the time | None of the time | |
Medical Resource Subscale | ||||||
M1 | In the past 6 months, how many separate times have you visited your doctor, specifically about your ear problem? | |||||
More than 6 times | 5–6 times | 3–4 times | 1–2 times | None | ||
M2 | In the past 6 months, how many separate times have you used oral antibiotics to treat your ear infection? | |||||
More than 6 times | 5–6 times | 3–4 times | 1–2 times | None | ||
M3 | In the past 6 months, how many separate times have ear drops been necessary to treat your ear condition? | |||||
More than 6 times | 5–6 times | 3–4 times | 1–2 times | None |