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TINNITUS CLINIC
TINNITUS DESCRIPTION AND HISTORY
NAME___________________________________ AGE______ BIRTHDATE____________________
LAST FIRST INITIAL MONTH DATE YEAR
ADDRESS__________________________________________ PHONE________________________
HOME
_________________________________________________ ________________________
CITY STATE ZIP CODE WORK
WHAT IS YOUR HEIGHT:______ WEIGHT:_____ EYE COLOR:_____ RIGHT OR LEFT HANDED?
(CIRCLE ONE)
REFERRED TO TINNITUS CLINIC BY:________________________________________________
NAME LOCATION
=============================================================================== |
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1. |
WHEN DID YOU BECOME AWARE OF HAVING TINNITUS (NOISE OR SOUNDS IN YOUR EARS
OR HEAD)?__________________________________________________________________ |
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2. |
DID YOU BECOME AWARE OF YOUR TINNITUS SUDDENLY OR GRADUALLY? ______________ |
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3. |
BEFORE THAT DID YOU EXPERIENCE ANY EPISODES OF TEMPORARY OR MILDER
TINNITUS? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | (CHECK ALL THAT APPLY IN THE LIST BELOW) |
| |
| [] AFTER EXPOSURE TO LOUD SOUND |
| [] ASSOCIATED WITH COLDS, FLU, OR ALLERGY |
| PROBLEM |
| [] ANY OTHER TIME(S)________________________________________ |
| DESCRIBE |
+--------------------------------------------------------------+ |
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4. |
HOW LONG HAS TINNITUS BEEN A SIGNIFICANT PROBLEM FOR__________________ |
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5. |
WERE ILLNESS, ACCIDENT OR OTHER SPECIAL CIRCUMSTANCES ASSOCIATED WITH THE
ONSET OF YOUR PRESENT TINNITUS? ___________________________________________
___________________________________________________________________________
PLEASE EXPLAIN BRIEFLY |
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6. |
DOES YOUR TINNITUS CONSIST OF ONE SOUND OR MORE THAN ONE SOUND? ___________ |
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7. |
IN THE LIST BELOW, PLEASE CHECK SOUND(S) THAT MOST CLOSELY RESEMBLE YOUR
TINNITUS:
[] RINGING [] HISSING [] SIZZLING [] PULSATING
[] CLEAR TONE [] BUZZING [] TRANSFORMER NOISE [] POUNDING
[] MORE THAN ONE TONE [] HUM [] HIGH TENSION WIRE [] OCEAN ROAR
[] WHISTLE [] MUSIC [] CRICKETS, INSECTS [] CLICKING
[] OTHER: _________________________________________________________________
DESCRIBE |
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HAS YOUR TINNITUS SOUNDED ABOUT THE SAME (IN TERMS OF TYPE OF SOUND) SINCE
IT FIRST STARTED, OR HAS THE TYPE OF SOUND CHANGED? _______________________
DESCRIBE CHANGE(S) IF ANY |
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8. |
IF YOU HEAR MORE THAN ONE SOUND, WHICH SOUND IS PREDOMINANT OR MOST
BOTHERSOME? _______________________________________________________________ |
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9. |
WHERE DOES YOUR PREDOMINANT TINNITUS SOUND APPEAR TO BE COMING FROM?
___________________________________________________________________________ |
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IF IN MORE THAN ONE LOCATION, WHERE IS IT WORST: __________________________ |
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10. |
IF YOU DO HEAR OTHER TINNITUS SOUNDS BESIDES THE PREDOMINANT ONE, PLEASE
DESCRIBE:
TYPE OF SOUND LOCATION
SOUND #2 IS:_____________________, APPEARS TO BE LOCATED IN:_______________
SOUND #3 IS:_____________________, APPEARS TO BE LOCATED IN:_______________
DO YOU HEAR ANY ADDITIONAL SOUNDS NOT ALREADY DESCRIBED? [] NO [] YES
___________________________________________________________________________
INDICATE TYPE OF SOUND AND WHERE LOCATED |
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11. |
DO YOU HEAR YOUR PREDOMINANT TINNITUS SOUND ALL THE TIME OR IS IT SOMETIMES
ABSENT?
[] HEARD ALL THE TIME [] SOMETIMES ABSENT:____________________________
APPROXIMATE PERCENT OF TIME HEARD |
|
|
SINCE YOUR TINNITUS STARTED, HAS IT ALTERED IN REGARD TO THE PERCENT OF
TIME HEARD?
[] NO CHANGE [] YES, PERCENT OF TIME HAS CHANGED [] NOT SURE
+-------------------------------------------------------------+
IF YES:--> | [] I NOW HEAR TINNITUS MORE OF THE TIME THAN AT FIRST |
| [] I NOW HEAR TINNITUS LESS OF THE TIME THAN AT FIRST |
+-------------------------------------------------------------+ |
|
12. |
SINCE IT STARTED HAS THE LOCATION OF YOUR TINNITUS CHANGED? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | PLEASE DESCRIBE CHANGES:____________________________________ |
| WERE CHANGES RELATED TO ILLNESS, ACCIDENT, OR OTHER EVENT? |
| ____________________________________________________________ |
| IF YES, DESCRIBE BRIEFLY |
+--------------------------------------------------------------+ |
|
13. |
SINCE IT STARTED HAS THE LOUDNESS OF YOUR TINNITUS CHANGED? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | HAS IT GROWN: [] LOUDER [] SOFTER |
| [] BOTH TYPES OF CHANGE OCCURRED |
| WERE CHANGES RELATED TO ILLNESS, ACCIDENT, OR OTHER EVENT? |
| ____________________________________________________________ |
| IF YES, DESCRIBE BRIEFLY |
+--------------------------------------------------------------+ |
|
14. |
DOES THE LOUDNESS OF YOUR TINNITUS TEND TO FLUCTUATE UP AND DOWN?
[] NO [] YES
+-------------------------------------------------------------+
IF YES:--> | INDICATE SIZE OF FLUCTUATIONS: [] BARELY NOTICEABLE |
| [] MODERATE |
| [] VERY MARKED |
| [] VARIABLE IN SIZE |
| HOW OFTEN DO FLUCTUATIONS OCCUR? |
| [] DAILY [] SEVERAL PER WEEK |
| [] SEVERAL PER MONTH [] RARELY |
+-------------------------------------------------------------+ |
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15. |
ON THE SCALE BELOW PLEASE INDICATE THE LOUDNESS OF YOUR USUAL TINNITUS
(CIRCLE NUMBER)
0 1 2 3 4 5 6 7 8 9 10
_______________________________________________________________________
VERY QUIET INTERMEDIATE LOUDNESS VERY LOUD |
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16. |
HAVE YOU NOTICED CHANGES IN TINNITUS LOUDNESS CAUSED BY ANY OF THE
FOLLOWING: (CHECK ALL THAT APPLY & INDICATE WHETHER THEY
MAKE TINNITUS LOUDER OR SOFTER)
[] TOBACCO USE _______________
[] MARIJUANA _______________
[] ALCOHOLIC BEVERAGES _______________
[] CAFFEINE (COFFEE, TEA, COLA, ETC) _______________
[] ASPIRIN _______________
[] TYLENOL, OTHER PAIN-KILLER _______________
[] NO, NONE OF THE ABOVE ALTERS MY TINNITUS |
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17. |
HAVE YOU NOTICED CHANGES IN TINNITUS LOUDNESS CAUSED BY ANY OF THE
FOLLOWING: (CHECK ALL THAT APPLY & INDICATE WHETHER THEY
MAKE TINNITUS LOUDER OR SOFTER)
[] NOISE EXPOSURE _______________
[] STRESS OR FATIGUE _______________
[] COLDS, SINUS, HAYFEVER _______________
[] COUGHING OR SNEEZING _______________
[] MOVING JAW, CLENCHING TEETH _______________
[] CHANGES IN ALTITUDE _______________
[] ALTERATIONS IN BODY POSITION _______________
[] NO, NONE OF THE ABOVE ALTERS MY TINNITUS |
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18. |
IS THERE ANYTHING ELSE THAT YOU HAVE NOTICED CAUSES CHANGES IN YOUR
TINNITUS?
___________________________________________________________________________
INDICATE AGENT CAUSING CHANGE INDICATE NATURE OF CHANGE |
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19. |
DOES YOUR TINNITUS INTERFERE WITH SLEEP?
[] NO [] YES, SOMETIMES [] YES, OFTEN |
|
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+--------------------------------------------------------------+
IF YES:--> | TYPE OF INTERFERENCE: [] TROUBLE GETTING TO SLEEP |
| [] TROUBLE STAYING ASLEEP |
| [] OTHER____________________________ |
| HOW SEVERE IS PROBLEM: [] MILD [] MODERATE [] SEVERE |
+--------------------------------------------------------------+
HAVE YOU FOUND ANYTHING THAT HELPS YOU SLEEP:______________________________
DESCRIBE |
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20. |
DO YOU FEEL TINNITUS HAS CAUSED YOU SIGNIFICANT PROBLEMS IN ANY OF
THESE WAYS:
MAKES YOU FEEL IRRITABLE OR NERVOUS [] NO [] SOMETIMES [] YES
MAKES YOU FEEL TIRED OR ILL [] NO [] SOMETIMES [] YES
MAKES IT DIFFICULT TO RELAX [] NO [] SOMETIMES [] YES |
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21. |
HAS TINNITUS CAUSED YOU ANY OF THE FOLLOWING PROBLEMS:
MADE IT UNCOMFORTABLE TO BE IN QUIET [] NO [] SOMETIMES [] YES
MADE IT DIFFICULT TO CONCENTRATE [] NO [] SOMETIMES [] YES
MADE IT HARDER TO INTERACT PLEASANTLY [] NO [] SOMETIMES [] YES
WITH OTHERS |
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22. |
ANY OTHER PROBLEMS TINNITUS HAS CAUSED YOU:
(A) AT WORK:______________________________________________________________
DESCRIBE PROBLEM
(B) AT HOME OR IN LEISURE TIME:___________________________________________
___________________________________________________________________________
DESCRIBE PROBLEM |
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23. |
HAVE YOU CHANGED JOBS BECAUSE OF TINNITUS? [] NO [] YES:_________________
___________________________________________________________________________
EXPLAIN CHANGE |
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24. |
HAVE YOU MADE OTHER SIGNIFICANT CHANGES IN YOUR LIFESTYLE BECAUSE OF
TINNITUS? [] NO [] YES:_______________________________________________
EXPLAIN |
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25. |
HOW MUCH OF AN EFFORT IS IT FOR YOU TO IGNORE YOUR TINNITUS WHEN IT IS
PRESENT?
[] CAN EASILY IGNORE IT
[] CAN IGNORE IT WITH SOME EFFORT
[] IT TAKES CONSIDERABLE EFFORT TO IGNORE IT
[] CAN NEVER IGNORE IT |
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26. |
HOW MUCH DISCOMFORT DO YOU USUALLY EXPERIENCE WHEN YOUR TINNITUS IS
PRESENT?
[] NO DISCOMFORT [] MODERATE DISCOMFORT
[] MILD DISCOMFORT [] A GREAT DEAL OF DISCOMFORT |
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27. |
HOW MUCH INTERFERENCE DOES TINNITUS CAUSE YOU FOR THE FOLLOWING ACTIVITIES?
NONE SLIGHT MODERATE A GREAT DEAL OF
INTERFERENCE INTERFERENCE INTERFERENCE
A. WORK ACTIVITIES ______ ______ ______ ______
B. SOCIAL ACTIVITIES ______ ______ ______ ______
C. OVERALL ENJOYMENT ______ ______ ______ ______ |
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28. |
HAVE YOU PREVIOUSLY SOUGHT MEDICAL HELP FOR YOUR TINNITUS? [] NO [] YES
___________________________________________________________________________
___________________________________________________________________________
IF YES, PLEASE INDICATE WHERE AND WHEN |
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29. |
HAVE YOU PREVIOUSLY TRIED ANY OF THE FOLLOWING TYPES OF TREATMENT FOR
TINNITUS? +------------------------------------------------------+
[] NO [] YES:--> | AMOUNT |
| DATES OF RELIEF |
| [] BIOFEEDBACK _______ _______ |
| [] DRUG THERAPY:_________________ _______ _______ |
| DESCRIBE |
| [] MASKING _______ _______ |
| [] HYPNOSIS OR ACUPUNCTURE _______ _______ |
| [] OTHER:________________________ _______ _______ |
| DESCRIBE |
+------------------------------------------------------+ |