Tinnitus Archive

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Demographic Information

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