Tinnitus Archive
>
Data Sets
>
1
>
Forms
>
Coding
>
Tinnitus Recommendations
Tinnitus Recommendations
TINNITUS DATA REGISTRY - TINNITUS RECOMMENDATIONS |
===============================================================================
|
CONCLUSIONS AND RECOMMENDATIONS: |
___ |
4. |
EXAMINER
use examiner codes |
RIGHT LEFT BINAURAL |
____ ____ ____ |
5a. |
EFFECT OF MASKERS
0 = no data
1 = no effect
2 = partial
3 = complete
7 = other, no comment
8 = other, see comments |
____ ____ ____ |
5b. |
EQUIPMENT USED FOR THIS EFFECT?
use equipment table |
____ ____ ____ |
5c. |
EASE OF MASKING
0 = no data
1 = masking not accomplished
2 = low levels
3 = medium level
4 = high levels
7 = other, no comment
8 = other, see comments |
____ ____ ____ |
6a. |
EFFECT OF AMPLIFICATION ALONE
see codes for 5A |
____ ____ ____ |
6b. |
EQUIPMENT USED FOR THIS EFFECT?
use equipment table |
____ ____ ____ |
6c. |
EASE OF MASKING
see codes for 5C |
____ ____ ____ |
7a. |
EFFECT OF TINNITUS INSTRUMENT
see codes for 5A |
____ ____ ____ |
7b. |
EQUIPMENT USED FOR THIS EFFECT?
use equipment table |
____ ____ ____ |
7c. |
EASE OF MASKING
see codes for 5C |
____ ____ ____ |
8. |
EQUIPMENT PRODUCING MOST EFFECTIVE MASKING
use equipment table |
___ |
9. |
RESIDUAL INHIBITION BY EAR LEVEL EQUIPMENT
use residual inhibition codes |
|
|
RESIDUAL INHIBITION:
0 = no data
1 = no
2 = partial
3 = complete
4 = complete + partial
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
___ |
10a. |
MASKING PROGRAM BENEFIT THIS PATIENT
0 = no data
1 = no
2 = yes
7 = other, no comment
8 = other, see comments |
|
|
IF NO: |
___ ___ ___ |
10b. |
REASON(S) WHY
0 = no data
1 = could not mask effectively, no further info
2 = tinnitus is not severe enough / not enough of a problem
3 = patient prefers tinnitus to masking sound
4 = patient is not ready to participate in a masking program
at this time
5 = intensity necessary for masking is too high
6 = could not mask due to hearing loss
7 = possible medical problem, patient will seek consultation
before considering masking program
8 = masking aggravates tinnitus
77 = other, no comment
88 = other, see comments |
___ |
11a. |
MASKING AND/OR HEARING AID RECOMMENDED?
0 = no data
1 = no
2 = yes
3 = yes, hearing aid only
4 = yes, HA + TM or TI
7 = other, no comment
8 = other, see comments |
|
|
use equipment table
leave blank if not applicable |
___ |
11b. |
RIGHT EAR |
___ |
11c. |
LEFT EAR |
___ |
12a. |
PATIENT INTERESTED IN MASKING PROGRAM?
0 = no data
1 = no
2 = yes
3 = waiting for authorization
4 = cannot afford
7 = other, no comment
8 = other, see comments |
___ ___ ___ |
12b. |
REASON(S) WHY:
see codes for 10B |
___ ___ ___ |
13. |
OTHER RECOMMENDATIONS MADE
0 = no data
1 = no other recommendation
2 = medical referral
3 = dental referral
4 = hearing conservation (ear protection, avoid loud sounds)
5 = biofeedback / stress management
6 = electrical stimulation
7 = FM masking at home
8 = Custom tape (excludes OHRC tape)
9 = OHRC masking tape
77 = other, no comment
88 = other, see comments |
___ |
14. |
PATIENT REFERRED TO
use referral codes |
___ |
15. |
TIME INTERVAL PATIENT ASKED TO REPORT BACK
0 = no data
1 = not asked to report back
2 = < 1 mo
3 = 1 - 3 mos
4 = more than 3 mos, less than 6 mos
5 = more than 6 mo, less than 1 yr
6 = more than 1 yr
7 = if tinnitus worsens
77 = other, no comment
88 = other, see comments |
===============================================================================
|
TINNITUS EVALUATION RESULTS - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
=============================================================================== |