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 |
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IF YES: |
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TYPES OF DIFFICULTIES - SPEECH
leave blank if not applicable
0 = no data
1 = no
2 = yes
7 = other, no comment
8 = other, see comments |
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51b. |
Speech sounds muffled or indistinct |
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51c. |
Difficulty hearing speech in noisy surroundings |
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51d. |
Problems with telephone |
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51e. |
Other problems hearing speech:________________________________
describe |
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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 |
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IF YES: |
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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 |
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52b. |
Soft or weak sounds |
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52c. |
High pitched sounds |
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52d. |
Listening to radio or TV |
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52e. |
Other hearing problems:_______________________________________
describe |
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IF YES TO PROBLEMS HEARING SPEECH OR OTHER SOUNDS: |
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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 |
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53b. |
FIRST NOTICED CHANGES IN HEARING (duration category)
use Duration codes |
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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 |
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53c. |
DATE FIRST NOTICED CHANGES IN HEARING
leave blank if date not available
0 = no data
MONTH: 1 - 12
YEAR: 1 - 99 |
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53d. |
NOTICED ADDITIONAL CHANGES SINCE ONSET?
0 = no data
1 = no
2 = yes |
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IF YES:____________________________________________________________
describe |
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53e. |
ONSET OF HEARING GRADUAL OR SUDDEN?
use Rapidity codes |
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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 |
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53f. |
IF SUDDEN, WAS IT ASSOCIATED WITH ANYTHING?
see Onset associations and Symptoms codes
leave blank if not applicable |
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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 |
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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 |
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54a. |
FLUCTUATING HEARING?
0 = no data
1 = no
2 = yes
6 = unsure
7 = other, no comment
8 = other, see comments |
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IF YES: |
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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 |
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55a. |
LOUD SOUNDS MORE UNPLEASANT?
0 = no data
1 = no
2 = yes
6 = unsure
7 = other, no comment
8 = other, see comments |
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IF YES: |
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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 |
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55c. |
APPROXIMATE DATE OF CHANGE
leave blank if date not available
MONTH: 1 - 12; 0 = no data
YEAR: 1 - 99 |
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56 - 59. |
NOISE EXPOSURE HISTORY:
0 = no data
1 = no
2 = yes |
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DESCRIPTION 1.CODE 2.DATE BEGAN 3.OVERALL 4.EAR 5.SIGNI-
mm / yy DURATION* PROTEC- FICANCE
mm / yy TION |
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A. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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B. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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C. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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D. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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E. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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F. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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G. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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H. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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I. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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J. |
___________________ ___ ___ / ___ ___ / ___ ___ |
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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 |
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SIGNIFICANCE:
0 = no data
1 = none
2 = possible
3 = yes |
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*OVERALL DURATION: If less than 1 month, code as 01 / 00 |
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K. |
SIGNIFICANCE - OCCUPATIONAL NOISE EXPOSURE
use Significance codes |
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SIGNIFICANCE:
0 = no data
1 = none
2 = possible
3 = yes |
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L. |
SIGNIFICANCE - MILITARY NOISE EXPOSURE
use Significance codes |
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SIGNIFICANCE:
0 = no data
1 = none
2 = possible
3 = yes |
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M. |
SIGNIFICANCE - RECREATIONAL NOISE EXPOSURE
use Significance codes |
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SIGNIFICANCE:
0 = no data
1 = none
2 = possible
3 = yes |
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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 |
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61. |
OTHER ENVIRONMENTAL HAZARDS?
0 = no data
1 = no
2 = yes, describe in comments |
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62a. |
MAJOR OCCUPATION 1ST LISTED
use Occupation codes |
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62b. |
MAJOR OCCUPATION 2ND LISTED
use Occupation codes |
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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 |
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IF YES: |
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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 |
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64. |
WORSE PROBLEM?
0 = no data
1 = hearing
2 = tinnitus
3 = equal
6 = not sure
7 = other, no comments
8 = other, see comments |
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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
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