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Tinnitus Recommendations

TINNITUS DATA REGISTRY - TINNITUS RECOMMENDATIONS
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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
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TINNITUS EVALUATION RESULTS - GENERAL COMMENT FIELD COMMENTS:______________________________________________________________________ ===============================================================================