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> Demographic Information
Demographic Information
TINNITUS DATA REGISTRY - DEMOGRAPHIC INFORMATION
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MORE THAN 42 DX'S
(leave blank if answer is no)
2 = yes
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CLINIC 0 = no data 1 = tinnitus clinic 7 = other, no further info 8 = other, see comments
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SEX 0 = no data 1 = male 2 = female
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AGE
leave blank if age not known
YEARS OF AGE: 01 - 99
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WEIGHT (in pounds)
leave blank if weight not known
POUNDS: 001 - 999
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HEIGHT (in inches)
leave blank if height not known
INCHES: 01 - 120
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EYE COLOR 0 = no data 1 = brown 2 = blue 3 = green, hazel, grey 7 = other, no further info 8 = other, see comments
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HAND PREFERENCE 0 = no data 1 = right handed 2 = left handed 3 = ambidextrous 6 = unsure 7 = other, no comment 8 = other, see comments
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DEMOGRAPHIC INFORMATION - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________ ===============================================================================