| TINNITUS DATA REGISTRY - TINNITUS HISTORY |
|
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|
| __ |
TINNITUS HISTORY RELIABILITY
0 = no data
1 = Good
2 = Fair
3 = Poor
8 = other, see comments |
|
===============================================================================
|
| ___ ___ |
1a. |
DATE FIRST AWARE OF TINNITUS (MONTH, YEAR)
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 87
88 / 88 = other, see comments |
| ___ |
1b. |
DURATION CATEGORY
use Duration codes |
|
|
DURATION:
0 = No data
1 = Less than or equal 1 year
2 = More than 1, less than / equal to 2 years
3 = More than 2, less than / equal to 5 years
4 = More than 5, less than / equal to 10 years
5 = More than 10, less than / equal to 20 years
6 = More than 20 years
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ |
2. |
SUDDEN OR GRADUAL?
use Rapidity codes |
|
|
RAPIDITY OF ONSET:
0 = No data
1 = Gradual (more than 1 month)
2 = Rapid (more than 1 week, less than / equal to 1 month)
3 = Sudden (less than / equal 1 week)
6 = Unsure
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ ___ ___ |
3. |
PRIOR TINNITUS?
0 = no data
1 = none recalled
2 = after loud sounds
3 = with colds, flu, other ENT problems
4 = with drugs or other treatments (see comments)
7 = other, no comment
8 = other, see comments |
| ___ |
4a. |
TINNITUS MORE OF A PROBLEM SINCE ONSET?
0 = no data
1 = no
2 = yes
3 = unsure |
|
|
IF YES: |
| ___ ___ |
4b. |
DATE SINCE SIGNIFICANT PROBLEM
leave blank if date not available
MONTH: 1 - 12;
YEAR: 1 - 87
88 / 88 = other, see comments |
| ___ |
4c. |
DURATION CATEGORY
use Duration codes |
|
|
DURATION:
0 = No data
1 = Less than or equal 1 year
2 = More than 1, less than / equal to 2 years
3 = More than 2, less than / equal to 5 years
4 = More than 5, less than / equal to 10 years
5 = More than 10, less than / equal to 20 years
6 = More than 20 years
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ |
4d. |
SUDDEN OR GRADUAL?
use Rapidity codes |
|
|
RAPIDITY OF ONSET:
0 = No data
1 = Gradual (more than 1 month)
2 = Rapid (more than 1 week, less than / equal to 1 month)
3 = Sudden (less than / equal 1 week)
6 = Unsure
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ ___ |
4e. |
PATIENT ASSOCIATES CHANGE IN TINNITUS WITH:
see Onset associations / Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ ___ |
5a. |
PATIENT ASSOCIATED ONSET WITH:
see Onset associations / Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| DESCRIBE SURGERY: |
5b. |
__________________________________________________________ |
| DESCRIBE ILLNESS: |
5c. |
__________________________________________________________ |
| DESCRIBE DRUG: |
5d. |
__________________________________________________________ |
| DESCRIBE OTHER: |
5e. |
__________________________________________________________ |
| ___ ___ ___ |
5f. |
SYMPTOMS ASSOCIATED WITH ONSET OF TINNITUS:
see Onset associations / Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ |
6. |
ONE SOUND OR MORE THAN ONE?
0 = no data available
1 = one
2 = two
3 = three
4 = more than 3, can describe
5 = more than 1, unsure how many
6 = uncertain if more than 1
7 = other, no comment
8 = other, see comments |
|
7a. |
SOUNDS RESEMBLING TINNITUS
(coded later - see Q8 below) |
| ___ |
7b. |
HAS TYPE OF SOUND CHANGED IN PAST?
0 = no data
1 = no change
2 = yes
3 = patient not sure
7 = other, no comment
8 = other, see comments |
|
|
IF TYPE OF SOUND HAS CHANGED IN PAST: |
| ___ ___ ___ |
7c. |
PATIENT ASSOCIATED PAST SOUND CHANGE WITH:
use Onset associations and Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ |
7d. |
DURATION OF PRESENT TINNITUS SOUNDS
use Duration codes |
|
|
DURATION:
0 = No data
1 = Less than or equal 1 year
2 = More than 1, less than / equal to 2 years
3 = More than 2, less than / equal to 5 years
4 = More than 5, less than / equal to 10 years
5 = More than 10, less than / equal to 20 years
6 = More than 20 years
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ ___ |
7e. |
DATE OF SOUND CHANGE
leave blank if date not available
MONTH: 1 - 12; 0 = no month date available
YEAR: 1 - 99 |
| ___ ___ ___ |
8. |
SOUNDS THAT RESEMBLE PREDOMINANT TINNITUS SOUND:
use Sound type codes |
|
|
SOUND TYPE:
0 = no data
1 = ringing
2 = clear tone
3 = more than 1 tone
4 = whistle
5 = hissing
6 = buzzing
7 = hum
8 = music
9 = sizzling
10 = transformer noise
11 = hi tension wire
12 = crickets
13 = pulsating
14 = pounding
15 = ocean roar
16 = clicking
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| IF PREDOMINANT SOUND(S) ARE VARIABLE, CODE = 88 AND DESCRIBE IN COMMENTS
IF TWO EARS DIFFER IN TYPE, BUT ARE EQUAL IN PREDOMINANCE,CODE = 88 AND
DESCRIBE IN COMMENTS |
| ___ ___ ___ |
9a. |
LOCATION OF PREDOMINANT SOUND:
If predominant sound(s) are variable, code as 88
If two ears differ in type, but are equal in predominance,
code as 88
use Location codes |
|
|
LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form |
| ___ |
9b. |
LOCATION WHERE WORST:
use Location codes |
|
|
LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form |
| ___ ___ ___ |
9c. |
ALL TINNITUS LOCATIONS
use Location codes |
|
|
LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form |
|
|
IF MORE THAN ONE SOUND TYPE: |
| ___ |
10a. |
SOUND # 2, TYPE
use Sound type codes |
|
|
SOUND TYPE:
0 = no data
1 = ringing
2 = clear tone
3 = more than 1 tone
4 = whistle
5 = hissing
6 = buzzing
7 = hum
8 = music
9 = sizzling
10 = transformer noise
11 = hi tension wire
12 = crickets
13 = pulsating
14 = pounding
15 = ocean roar
16 = clicking
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ ___ ___ |
10b. |
SOUND # 2, LOCATION
use Location codes |
|
|
LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form |
| ___ |
10c. |
SOUND # 3, TYPE
use Sound type codes |
|
|
SOUND TYPE:
0 = no data
1 = ringing
2 = clear tone
3 = more than 1 tone
4 = whistle
5 = hissing
6 = buzzing
7 = hum
8 = music
9 = sizzling
10 = transformer noise
11 = hi tension wire
12 = crickets
13 = pulsating
14 = pounding
15 = ocean roar
16 = clicking
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ ___ ___ |
10d. |
SOUND # 3, LOCATION
use Location codes |
|
|
LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form |
| ___ |
10e. |
ADDITIONAL SOUNDS HEARD?
0 = no data
1 = none
2 = patient not sure
3 = yes, no further info
4 = yes, see comments
7 = other, no comment
8 = other, see comments |
| ___ |
11a. |
INTERMITTENCY OF PREDOMINANT SOUND:
PERCENT OF TIME CURRENTLY HEARD
0 = no data
1 = 100 % (constant)
2 = heard more than or equal 50 %
3 = heard less than 50 %
4 = heard part of the time, no further information
7 = other, no comment
8 = other, see comments |
| ___ |
11b. |
PREDOMINANT SOUND, PAST CHANGES IN % OF TIME HEARD:
0 = no data
1 = no changes
2 = now hear it more
3 = now hear it less
4 = both changes have occurred
6 = patient not sure of changes
7 = other, no comment
8 = other, see comments |
| ___ |
12a. |
HAS LOCATION CHANGED SINCE ONSET?
0 = no data
1 = no changes
2 = began in right ear, now in both ears
3 = began in left ear, now in both ears
4 = began in 1 location, now in completely different tion
5 = location too variable to code
6 = location changed, no further info
7 = other, no comment
8 = other, see comments |
|
|
IF LOCATION HAS CHANGED SINCE ONSET: |
| ___ ___ |
12b. |
PATIENT ASSOCIATED LOCATION CHANGE(S) WITH:
use Onset associations and Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ |
12c. |
DURATION OF PRESENT TINNITUS LOCATION:
use Duration codes |
|
|
DURATION:
0 = No data
1 = Less than or equal 1 year
2 = More than 1, less than / equal to 2 years
3 = More than 2, less than / equal to 5 years
4 = More than 5, less than / equal to 10 years
5 = More than 10, less than / equal to 20 years
6 = More than 20 years
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ ___ |
12d. |
DATE OF LOCATION CHANGE:
leave blank if date not available
MONTH: 01 - 12; 00 = no month date available
YEAR: 01 - 99 |
| ___ |
13a. |
SINCE ONSET, HAS LOUDNESS OF TINNITUS CHANGED?
(long term trend)
0 = no data
1 = no changes
2 = grown louder
3 = grown softer
4 = both changes have occurred
6 = patient not sure
7 = other, no comments
8 = other, see comments |
|
|
IF LOUDNESS OF TINNITUS HAS CHANGED SINCE ONSET: |
| ___ |
13b. |
WERE CHANGES GRADUAL OR SUDDEN?
0 = no data
1 = gradual (changes occurred more than 1 month)
2 = sudden (changes occurred less than or equal to 1 month)
3 = both types of changes have occurred
6 = patient not sure
7 = other, no comment
8 = other, see comments |
| ___ ___ |
13c. |
PATIENT ASSOCIATED LOUDNESS CHANGES WITH:
use Onset associations and Symptoms codes |
|
|
ONSET ASSOCIATIONS:
0 = no data
1 = nothing known
2 = ear infection, inflammation
3 = head injury (excludes codes 5 and 6)
4 = whiplash / cervical trauma
5 = explosion (fireworks, gunshot, etc)
6 = brief intense noise (excludes codes 5 and 9)
7 = "sudden hearing loss"
8 = barotrauma
9 = longer duration noise (excludes codes 5 and 6)
10 = stress
11 = allergies / hayfever
12 = surgery, see General Comment Field for appropriate form
13 = cold / sinus infection
14 = illness, see General Comment Field for appropriate form
15 = drug, see General Comment Field for appropriate form
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
|
|
ASSOCIATED SYMPTOMS:
0 = no data
1 = nothing known
40 = tinnitus
41 = hearing loss
42 = fullness in ear
43 = fever
44 = ear pain
45 = dizziness (any type)
46 = nausea
47 = headache
48 = facial numbness
49 = neck pain (excluding whiplash)
50 = depression
51 = pain / other, see General Comment Field for appropriate form
52 = hearing loss denied
53 = concussion
54 = unconsciousness
55 = skull fracture
56 = vertebral fracture
77 = other, no comment
88 = other, see General Comment Field for appropriate form |
| ___ |
13d. |
DURATION OF PRESENT TINNITUS LOUDNESS:
use Duration codes |
|
|
DURATION:
0 = No data
1 = Less than or equal 1 year
2 = More than 1, less than / equal to 2 years
3 = More than 2, less than / equal to 5 years
4 = More than 5, less than / equal to 10 years
5 = More than 10, less than / equal to 20 years
6 = More than 20 years
7 = Other, no comment
8 = Other, see General Comment Field for appropriate form |
| ___ ___ |
13e. |
DATE OF LOUDNESS CHANGE:
leave blank if date not available
MONTH: 1 - 12; 0 = no month date available
YEAR: 1 - 99 |
| ___ |
14a. |
DOES LOUDNESS TEND TO FLUCTUATE?
0 = no data
1 = no, loudness is constant
2 = barely noticeable / slight
3 = moderate
4 = very marked
5 = variable / unpredictable
6 = yes, no info on amount
7 = other, no comment
8 = other, see comments |
|
|
IF TINNITUS DOES FLUCTUATE IN LOUDNESS: |
| ___ |
14b. |
HOW OFTEN DO FLUCTUATIONS OCCUR?
use Frequency codes |
|
|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = several per month
3 = several per week
4 = daily
5 = yes, no info on amount
6 = patient not sure
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
| ___.___ |
15a. |
LOUDNESS OF USUAL TINNITUS
Code as a decimal value ( ie. if a value of 5 is circled,
code as 5.0 ; if a value is circled between 5 and 6,
code as 5.5)
If usual Tinnitus varies between value X and value Y,
or patient says that there is no usual level and circles
more than 1 value, use ALTERNATE LOUDNESS LEVEL |
| ___.___ |
15b. |
ALTERNATE LOUDNESS LEVEL
Code as a decimal value ( ie. if a value of 5 is circled,
code as 5.0 ; if a value is circled between 5 and 6,
code as 5.5)
leave blank if not applicable |
|
16. |
CHANGES IN TINNITUS CAUSED BY (following):
0 = no data available
1 = none reported
2 = yes, no info on type of change
3 = yes, louder
4 = yes, softer
5 = yes, quality / other change
6 = patient unsure
7 = 3 + 4
8 = 3 + 5
9 = 4 + 5
10 = 3 + 4 + 5
77 = other, no comment
88 = other, see comments |
| ___ |
A. |
Tobacco |
| ___ |
B. |
Marijuana |
| ___ |
C. |
Alcohol |
| ___ |
D. |
Caffeine |
| ___ |
E. |
Aspirin |
| ___ |
F. |
Tylenol, other painkiller |
|
17. |
CHANGES IN TINNITUS CAUSED BY (following):
use codes for Q16 |
| ___ |
A. |
Noise Exposure |
| ___ |
B. |
Stress or Fatigue |
| ___ |
C. |
Colds, Sinus, Hayfever |
| ___ |
D. |
Coughing or Sneezing |
| ___ |
E. |
Moving Jaw, Clenching Teeth |
| ___ |
F. |
Changes in Altitude |
| ___ |
G. |
Alterations in Body Position |
|
18. |
OTHER THINGS CAUSING CHANGES IN TINNITUS:
use codes for Q16 |
| ___ |
A. |
____________________________________________ (describe) |
| ___ |
B. |
____________________________________________ (describe) |
| ___ |
19a. |
DOES TINNITUS INTERFERE WITH SLEEP?
0 = no data
1 = no
2 = yes, sometimes
3 = yes, often
4 = yes, no info on frequency
6 = patient unsure
7 = other, no comment
8 = other, see comments |
|
|
IF TINNITUS INTERFERES WITH SLEEP: |
| ___ |
19b. |
TYPE OF SLEEP INTERFERENCE CAUSED BY TINNITUS:
0 = no data
1 = getting to sleep
2 = staying asleep
3 = both 1 and 2
6 = patient unsure
7 = other, no comment
8 = other, see comments |
| ___ |
19c. |
SEVERITY OF SLEEP PROBLEM CAUSED BY TINNITUS:
0 = no data
1 = mild
2 = moderate
3 = severe
6 = patient unsure
7 = other, no comment
8 = other, see comments |
|
19d. |
ANYTHING THAT HELPS YOU SLEEP? if yes, describe
______________________________________________________ |
|
20. |
HAS TINNITUS CAUSED ANY OF THE FOLLOWING PROBLEMS?
0 = no data
1 = no
2 = sometimes
3 = often
4 = yes, no info on frequency
6 = patient not sure
7 = other, no comment
8 = other, see comments |
| ___ |
A. |
Makes patient feel irritable or nervous |
| ___ |
B. |
Makes patient feel tired or ill |
| ___ |
C. |
Makes it difficult for patient to relax |
|
21. |
HAS TINNITUS CAUSED ANY OF THE FOLLOWING PROBLEMS?
use codes for Q20 |
| ___ |
A. |
Uncomfortable in quiet |
| ___ |
B. |
Difficulty concentrating |
| ___ |
C. |
Harder to interact pleasantly with others |
| ___ |
22a. |
OTHER TYPE OF PROBLEMS TINNITUS HAS CAUSED:
0 = no data
1 = none
2 = work related (other than change jobs)
3 = home or leisure related
4 = both 2 and 3
5 = yes, no info on type
7 = other, no comment
8 = other, see comments |
|
22b. |
WORK RELATED:_________________________________________________
describe |
|
22c. |
HOME / LEISURE RELATED:_______________________________________
describe |
| ___ |
23a. |
CHANGED JOBS BECAUSE OF TINNITUS?
0 = no data
1 = no
2 = yes
7 = other, no comment
8 = other, see comments |
|
23b. |
_______________________________________________________________
Explain change |
| ___ |
24a. |
OTHER SIGNIFICANT CHANGE IN LIFESTYLE?
use codes for Q23A |
|
24b. |
_______________________________________________________________
Explain change |
| ___ |
25. |
HOW MUCH EFFORT TO IGNORE TINNITUS?
0 = no data
1 = easily
2 = with some effort
3 = considerable effort
4 = never ignore it
7 = other, no comment
8 = other, see comments |
| ___ |
26. |
HOW MUCH DISCOMFORT DUE TO TINNITUS?
0 = no data
1 = none
2 = mild
3 = moderate
4 = great deal
7 = other, no comment
8 = other, see comments |
| ___ |
27a. |
HOW MUCH INTERFERENCE - WORK ACTIVITIES?
0 = no data
1 = none
2 = slight
3 = moderate
4 = great deal
7 = other, no comment
8 = other, see comments |
| ___ |
27b. |
HOW MUCH INTERFERENCE - SOCIAL ACTIVITIES?
use codes for Q27A |
| ___ |
27c. |
HOW MUCH INTERFERENCE - OVERALL ENJOYMENT?
use codes for Q27A |
| ___ |
28. |
SOUGHT PREVIOUS MEDICAL HELP?
0 = no data available
1 = no
2 = yes
7 = other, no comment
8 = other, see comments |
|
29a. |
PREVIOUS TREATMENTS TRIED?
leave blank if not applicable
0 = no data
1 = no relief
2 = fair or partial relief
3 = good or complete relief
4 = yes, no data on amount
6 = patient unsure
7 = other, no comment
8 = other, see comments |
| ___ |
1. |
Biofeedback |
| ___ |
2. |
Drug Therapy |
| ___ |
3. |
Masking |
| ___ |
4. |
Hypnosis / Acupuncture |
| ___ |
5. |
Other, see comments |
|
29b. |
ANYTHING ELSE WHICH HELPS OR HAS GIVEN RELIEF?
__________________________________________________________
if yes, describe
|
|
===============================================================================
|
| TINNITUS HISTORY - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
|
|
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|
| END OF TINNITUS HISTORY CODING FORM
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