| TINNITUS DATA REGISTRY - MEDICAL HISTORY |
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| ___ |
MEDICAL HISTORY RELIABILITY
0 = no data
1 = good
2 = fair
3 = poor
8 = other, see comments |
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30 - 33. |
Code illnesses and / or treatments on DX coding form |
| ___
___
___ |
34 - 36. |
EAR PROBLEMS OR INJURIES
0 = no data
1 = no
2 = yes, no further info
3 = yes, on DX coding form
7 = other, no comment
8 = other, see comments |
| ___ |
37a. |
DIZZINESS
use Frequency codes |
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|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
|
|
IF YES: |
| ___ ___ ___ |
37b. |
DIZZINESS TYPE
0 = no data
1 = turning or spinning
2 = faintness or light headedness
3 = loss of balance, feel may fall
7 = other, no comment
8 = other, see comments |
| ___ ___ |
37c. |
FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data |
| ___ ___ |
37d. |
ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes |
|
|
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 |
| ___ |
37e. |
RELATED TO TINNITUS CHANGES
0 = no data
1 = no changes
2 = yes, tinnitus is louder
3 = yes, tinnitus is softer
4 = yes, changes in tinnitus sound
5 = yes, no further info
7 = other, no comment
8 = other, see comments |
| ___ |
37f. |
SEVERITY OF PROBLEM
0 = no data
1 = mild
2 = moderate
3 = severe
4 = patient unsure
7 = other, no comment
8 = other, see comments |
| ___ |
38a. |
PAIN IN THE EAR
use Frequency codes |
|
|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
|
|
IF YES: |
| ___ |
38b. |
EAR(S) AFFECTED
0 = no data
1 = left
2 = right
3 = both
4 = varies
7 = other, no comment
8 = other, see comments |
| ___ ___ |
38c. |
FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data |
| ___ ___ |
38d. |
ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes |
|
|
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 |
| ___ |
38e. |
RELATED TO TINNITUS CHANGES
use codes for Q37e |
| ___ |
38f. |
SEVERITY OF PROBLEM
use codes for Q37f |
| ___ |
39a. |
FULLNESS IN THE EAR
use Frequency codes |
|
|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
|
|
IF YES: |
| ___ |
39b. |
EAR(S) AFFECTED
0 = no data
1 = left
2 = right
3 = both
4 = varies
7 = other, no comment
8 = other, see comments |
| ___ ___ |
39c. |
FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data |
| ___ ___ |
39d. |
ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes |
|
|
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 |
| ___ |
39e. |
RELATED TO TINNITUS CHANGES
use codes for Q37e |
| ___ |
39f. |
SEVERITY OF PROBLEM
use codes for Q37f |
|
40 - 41. |
Code medications for dizziness, ear pain and ear fullness
on DX coding form |
|
42. |
ALLERGIES:
0 = no data
1 = no
2 = yes
3 = formerly
6 = not sure
7 = other, no comment
8 = other, see comments |
| ___ |
A. |
FOOD |
| ___ |
B. |
POLLEN |
| ___ |
C. |
ANIMAL |
| ___ |
D. |
DRUGS |
| ___ |
E. |
OTHER:_________________________________________________________
describe |
| ___ |
43. |
HEADACHES
use Frequency codes |
|
|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
| ___ |
44. |
HEADACHE FREQUENCY CHANGE
0 = no data
1 = no change
2 = yes, less frequent
3 = yes, more frequent
5 = yes, no info on change
6 = not sure
7 = other, no comment
8 = other, see comments |
|
45. |
FREQUENCY OF (following):
use Frequency codes |
|
|
FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = several per month
3 = several per week
4 = daily
5 = yes, no info on amount
6 = patient not sure
7 = other, no comment
8 = other, see General Comment Field for appropriate form |
| ___ |
45a. |
TOBACCO USE |
| ___ |
45b. |
CAFFEINE USE |
| ___ |
45c. |
ALCOHOL USE |
| ___ |
45d. |
ASPIRIN USE |
| ___ |
45e. |
TYLENOL OR OTHER PAIN KILLER USE:_____________________________
describe |
| ___ |
46a. |
SIGNIFICANT HEAD / NECK INJURY
0 = no data
1 = no
2 = head injury
3 = neck injury
4 = head and neck injuries
5 = unsure of location
7 = other, no further info
8 = other, see comments |
|
|
IF YES: |
| ___ |
46b. |
MULTIPLE INJURIES
head injury = 854000
neck injury = 847000
both, unsure, no data = 849000
0 = no data
1 = one
2 = two
3 = three
4 = four
5 = > 4
6 = not sure how many
7 = other, no comment
8 = other, see comments
CODE HEAD AND / OR NECK INJURIES ON DX CODING FORM
If surgeries or treatments related to surgeries are associated with
tinnitus, code on DX coding for |
|
47. |
NON SIGNIFICANT SURGERIES:
(code age at onset)
YEARS: 1 - 97, or
98 = had surgery more than once, code on DX ng form
leave blank if not applicable or no data |
| ___ |
A. |
Tonsils / Adenoids |
| ___ |
B. |
Appendix |
| ___ |
C. |
Hernia |
| ___ |
D. |
Prostate |
| ___ |
E. |
Hysterectomy |
| ___ |
F. |
Caesarean Section |
| ___ |
G. |
Other:_______________________________________
describe |
|
48. |
Code other hospitalizations and associated
illnesses / treatments on DX coding form |
| ___ ___ ___ |
49. |
PAST COMMUNICABLE DISEASES
If disease occurred after age 21 and / or treatment of disease
are associated with tinnitus, code on DX coding form
0 = no data
1 = German Measles
2 = Hard Measles
3 = Unspecified Measles
4 = Mumps
5 = Chicken Pox
6 = Scarlet Fever
7 = Rheumatic Fever
8 = Whooping Cough
leave blank if not applicable
**CODE Diphtheria, Mononucleosis, Hepatitis, Tuberculosis,
Syphilis and Malaria on DX coding form |
| ___ |
50a. |
PROBLEMS WITH JAW OR TEETH
0 = no data
1 = no
2 = yes
3 = patient unsure
7 = other, no comment
8 = other, see comments |
|
|
IF YES: |
|
|
Age at Prior to Current
onset Tinnitus Problem |
|
50b. |
Pain or discomfort of jaw _____ _____ _____ |
|
50c. |
Jaw injury, surgery, infection _____ _____ _____ |
|
50d. |
Incorrect bite or other misalignment _____ _____ _____ |
|
50e. |
Clicking or other noise in jaw _____ _____ _____ |
|
50f. |
Pain or discomfort from dentures _____ _____ _____ |
|
50g. |
Grinding of teeth _____ _____ _____ |
|
50h. |
Oral surgery _____ _____ _____ |
|
50i. |
Other problem of teeth or jaw _____ _____ _____
_____________________________
describe |
|
|
Age at onset:
leave blank if not applicable
YEARS: 01 - 97; 00 = no data |
|
|
Prior to Tinnitus/Current Problem:
leave blank if not applicable
0 = no data
1 = no
2 = yes
3 = unsure
8 = other, see comments |
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| MEDICAL HISTORY - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
|
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| END OF MEDICAL HISTORY CODING FORM
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