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Audiological History

TINNITUS DATA REGISTRY - AUDIOLOGICAL HISTORY
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___ AUDIOLOGICAL HISTORY RELIABILITY 0 = no data 1 = Good 2 = Fair 3 = Poor 8 = other, see comments
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___ 51a. DIFFICULTIES HEARING SPEECH? 0 = no data 1 = no 2 = sometimes 3 = often 6 = not sure 7 = other, no comment 8 = other, see comments
IF YES:
TYPES OF DIFFICULTIES - SPEECH leave blank if not applicable 0 = no data 1 = no 2 = yes 7 = other, no comment 8 = other, see comments
___ 51b. Speech sounds muffled or indistinct
___ 51c. Difficulty hearing speech in noisy surroundings
___ 51d. Problems with telephone
___ 51e. Other problems hearing speech:________________________________ describe
___ 52a. PROBLEMS HEARING OTHER TYPES OF SOUND? 0 = no data 1 = no 2 = sometimes 3 = often 6 = not sure 7 = other, no comment 8 = other, see comments
IF YES:
TYPES OF PROBLEMS - OTHER SOUNDS leave blank if not applicable 0 = no data 1 = no 2 = yes 2 = yes 7 = other, no comment 8 = other, see comments
___ 52b. Soft or weak sounds
___ 52c. High pitched sounds
___ 52d. Listening to radio or TV
___ 52e. Other hearing problems:_______________________________________ describe
IF YES TO PROBLEMS HEARING SPEECH OR OTHER SOUNDS:
___ 53a. WHICH EAR(S) AFFECTED? 0 = no data 1 = left ear 2 = right ear 3 = both ears 6 = not sure 7 = other, no comment 8 = other, see comments
___ 53b. FIRST NOTICED CHANGES IN HEARING (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
___ ___ 53c. DATE FIRST NOTICED CHANGES IN HEARING leave blank if date not available 0 = no data MONTH: 1 - 12 YEAR: 1 - 99
___ 53d. NOTICED ADDITIONAL CHANGES SINCE ONSET? 0 = no data 1 = no 2 = yes
IF YES:____________________________________________________________ describe
___ 53e. ONSET OF HEARING GRADUAL OR SUDDEN? 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
___ ___ 53f. IF SUDDEN, WAS IT ASSOCIATED WITH ANYTHING? see Onset associations and Symptoms codes leave blank if not applicable
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
___ 54a. FLUCTUATING HEARING? 0 = no data 1 = no 2 = yes 6 = unsure 7 = other, no comment 8 = other, see comments
IF YES:
___ ___ ___ 54b. FLUCTUATIONS ASSOCIATED WITH ANYTHING? 0 = no data 1 = nothing known 2 = fluctuations in tinnitus loudness 3 = feelings of fullness 4 = changes in health 7 = other, no comment 8 = other, see comments
___ 55a. LOUD SOUNDS MORE UNPLEASANT? 0 = no data 1 = no 2 = yes 6 = unsure 7 = other, no comment 8 = other, see comments
IF YES:
___ 55b. CHANGE OCCURRED WHEN? 0 = no data 1 = before tinnitus 2 = after tinnitus 3 = about the same time as tinnitus 6 = unsure 7 = other, no comment 8 = other, see comments
___ ___ 55c. APPROXIMATE DATE OF CHANGE leave blank if date not available MONTH: 1 - 12; 0 = no data YEAR: 1 - 99
___ 56 - 59. NOISE EXPOSURE HISTORY: 0 = no data 1 = no 2 = yes
DESCRIPTION 1.CODE 2.DATE BEGAN 3.OVERALL 4.EAR 5.SIGNI- mm / yy DURATION* PROTEC- FICANCE mm / yy TION
A. ___________________ ___ ___ / ___ ___ / ___ ___
B. ___________________ ___ ___ / ___ ___ / ___ ___
C. ___________________ ___ ___ / ___ ___ / ___ ___
D. ___________________ ___ ___ / ___ ___ / ___ ___
E. ___________________ ___ ___ / ___ ___ / ___ ___
F. ___________________ ___ ___ / ___ ___ / ___ ___
G. ___________________ ___ ___ / ___ ___ / ___ ___
H. ___________________ ___ ___ / ___ ___ / ___ ___
I. ___________________ ___ ___ / ___ ___ / ___ ___
J. ___________________ ___ ___ / ___ ___ / ___ ___
EAR PROTECTION: 0 = no data 1 = none / seldom 2 = sometimes 3 = most / all of the time 4 = yes, not sure how often 7 = other, no comment 8 = other, see comments
SIGNIFICANCE: 0 = no data 1 = none 2 = possible 3 = yes
*OVERALL DURATION: If less than 1 month, code as 01 / 00
___ K. SIGNIFICANCE - OCCUPATIONAL NOISE EXPOSURE use Significance codes
SIGNIFICANCE: 0 = no data 1 = none 2 = possible 3 = yes
___ L. SIGNIFICANCE - MILITARY NOISE EXPOSURE use Significance codes
SIGNIFICANCE: 0 = no data 1 = none 2 = possible 3 = yes
___ M. SIGNIFICANCE - RECREATIONAL NOISE EXPOSURE use Significance codes
SIGNIFICANCE: 0 = no data 1 = none 2 = possible 3 = yes
___ ___ ___ 60. CONTACT WITH TOXIC OR HAZARDOUS CHEMICALS? 0 = no data 1 = no 2 = dry cleaning / related chemicals 3 = paint, lacquer, related solvents 4 = insecticides, defoliants 5 = chemical laboratory 6 = not sure 7 = other, no comment 8 = other, see comments
___ 61. OTHER ENVIRONMENTAL HAZARDS? 0 = no data 1 = no 2 = yes, describe in comments
___ 62a. MAJOR OCCUPATION 1ST LISTED use Occupation codes
___ 62b. MAJOR OCCUPATION 2ND LISTED use Occupation codes
___ 63a. WORN HEARING AID? 0 = no data 1 = no 2 = yes, left ear 3 = yes, right ear 4 = yes, both ears 5 = yes, no info on ear(s) 7 = other, no comment 8 = other, see comments
IF YES:
___ 63b. DOES AID AFFECT TINNITUS? leave blank if not applicable 0 = no data 1 = no effect 2 = tinnitus is better 3 = tinnitus is worse 7 = other, no comment 8 = other, see comments
___ 64. WORSE PROBLEM? 0 = no data 1 = hearing 2 = tinnitus 3 = equal 6 = not sure 7 = other, no comments 8 = other, see comments
___ 65. FAMILY HISTORY OF HEARING PROBLEMS? 0 = no data 1 = no 2 = yes, hearing 3 = yes, tinnitus 4 = yes, hearing and tinnitus 6 = patient unsure 7 = other, no comment 8 = other, see comments
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AUDIOLOGICAL HISTORY - GENERAL COMMENT FIELD COMMENTS:______________________________________________________________________
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END OF AUDIOLOGICAL HISTORY CODING FORM ===============================================================================