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Tinnitus Test Results

TINNITUS DATA REGISTRY - TINNITUS TEST RESULTS
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FINAL BEST MATCH:
PREDOMINANCE FREQUENCY (Hz) SL dB MATCHED TO LOW / HIGH RE STIM LE STIM SOUND TYPE(S) LOCATION(S)
____ 1a. _______ / _______ ____ ____ ____ ____ ____ ________
____ 1b. _______ / _______ ____ ____ ____ ____ ____ ________
____ 1c. _______ / _______ ____ ____ ____ ____ ____ ________
____ 1d. _______ / _______ ____ ____ ____ ____ ____ ________
SL dB: 88 = could not achieve loudness match 90 = SL dB known but stim location is not
SOUND TYPE: 0 = no data 1 = ringing 2 = clear tone 3 = more than 1 tone 4 = whistle 5 = hissing 6 = buzzing 7 = hum 8 = music 9 = sizzling 10 = transformer noise 11 = hi tension wire 12 = crickets 13 = pulsating 14 = pounding 15 = ocean roar 16 = clicking 77 = other, no comment 88 = other, see General Comment Field for appropriate form
LOCATION: use code 15 for both ears, not codes 1 and 5. 0 = no data 1 = left ear 2 = in head, left 3 = outside head, left 4 = not sure, left 5 = right ear 6 = in head, right 7 = outside head, right 8 = not sure, right 9 = fills head 10 = inside, top of head 11 = outside, top of head 12 = surrounds head 13 = back of head 14 = variable location 15 = both ears 17 = not sure of location 77 = other, no comments 88 = other, see General Comment Field for appropriate form
___ 1e. EXAMINERS CONFIDENCE IN PITCH MATCH 0 = no data 1 = good 2 = fair 3 = poor 8 = other, see comments
___ 2. EXAMINER use examiner codes
___ 3. ARE THERE OTHER SOUNDS BESIDES THOSE MATCHED? 0 = no data 1 = no 2 = yes 3 = unsure 7 = other, no comment 8 = other, see comments
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GENERAL DESCRIPTION OF TINNITUS (AT THE BEGINNING OF THE TEST):
___ 16. TINNITUS TODAY TYPICAL 0 = no data 1 = no, no further info 2 = yes 3 = sound quality different 4 = louder, more intense 5 = softer, less intense 7 = other, no comment 8 = other, see comments
___ ___ 17. LOCATION WHERE WORST 0 = no data 1 = left ear 2 = in head, left 3 = outside head, left 4 = not sure, left 5 = right ear 6 = in head, right 7 = outside head, right 8 = not sure, right 9 = fills head 10 = inside, top of head 11 = outside, top of head 12 = surrounds head 13 = back of head 14 = variable locations 15 = both ears 17 = not sure of location 77 = other, no comment 88 = other, see comments
___ 18. EVIDENCE OF PULSATION 0 = no data 1 = no 2 = yes 7 = other, no comment 8 = other, see comments
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TINNITUS MATCHING:
___ 19. LOCATION BEING MATCHED use location codes
LOCATION: use code 15 for both ears, not codes 1 and 5. 0 = no data 1 = left ear 2 = in head, left 3 = outside head, left 4 = not sure, left 5 = right ear 6 = in head, right 7 = outside head, right 8 = not sure, right 9 = fills head 10 = inside, top of head 11 = outside, top of head 12 = surrounds head 13 = back of head 14 = variable location 15 = both ears 17 = not sure of location 77 = other, no comments 88 = other, see General Comment Field for appropriate form
___ 20. STIMULUS TYPE 0 = no data 1 = pure tone 2 = narrow band noise 3 = wide band noise 4 = crickets 5 = tone + noise 7 = other, no comment 8 = other, see comments 9 = too complex to code
___ 21. TYPE OF EQUIPMENT 0 = no data 1 = tinnitus synthesizer 1 2 = tinnitus synthesizer 2 3 = tinnitus synthesizer 3 4 = tinnitus synthesizer 4 7 = other, no comment 8 = other, see comments
FREQUENCY (Hz) RIGHT EAR LEFT EAR THRESHOLD LOUDNESS STIM THRESHOLD LOUDNESS STIM MATCH dBSL MATCH dBSL
22a. 250 ____ ____ ____ ____ ____ ____
22b. 500 ____ ____ ____ ____ ____ ____
22c. 1000 ____ ____ ____ ____ ____ ____
22d. 2000 ____ ____ ____ ____ ____ ____
22e. 3000 ____ ____ ____ ____ ____ ____
22g. 5000 ____ ____ ____ ____ ____ ____
22h. 6000 ____ ____ ____ ____ ____ ____
22i. 7000 ____ ____ ____ ____ ____ ____
22j. 8000 ____ ____ ____ ____ ____ ____
22k. 9000 ____ ____ ____ ____ ____ ____
22l. 10000 ____ ____ ____ ____ ____ ____
22m. 11000 ____ ____ ____ ____ ____ ____
22n. 12000 ____ ____ ____ ____ ____ ____
OTHERS:
22o. ___ / ___ ____ ____ ____ ____ ____ ____
22p. ___ / ___ ____ ____ ____ ____ ____ ____
22q. ___ / ___ ____ ____ ____ ____ ____ ____
STIM dBSL: 88 = could not achieve loudness match 90 = too complex to code
___ 23. MATCHING TEST COMPLETED 0 = no data 1 = no attempts made 2 = test not completed 3 = test complete 7 = other, no comment 8 = other, see comments
___ 24. OCTAVE CONFUSION 0 = no data 1 = no 2 = yes 3 = did not test for 7 = other, no comment 8 = other, see comments
25. TINNITUS MASKING AND RESIDUAL INHIBITION TRIALS:
TRIAL# 1.FREQUENCY (Hz) 2.STIM 3.STIM 4.AMT OF 5.CONTRALATERAL 6.OTHER low / high EAR SL MASKING MASKING? EFFECTS A.____ ____ / ____ ____ ____ ____ ____ ____ 7.RI STIM 8.CRI 9.PRI 10.CONTRALATERAL 11.OTHER SL MM/SS MM/SS RI? EFFECTS ____ __/__ __/__ ____ ____ B.____ ____ __/__ __/__ ____ ____ ____ __/__ __/__ ____ ____ C.____ ____ __/__ __/__ ____ ____ ____ __/__ __/__ ____ ____ D.____ ____ __/__ __/__ ____ ____ ____ __/__ __/__ ____ ____ STIM EAR: 0 = no data 1 = left ear 2 = right ear 3 = both ears STIM SL: dB SL: 00 - 79, or: 88 = could not mask at limits of equipment 90 = too complex to code AMT OF MASKING: 0 = no data 1 = none 2 = partial 3 = complete 7 = other, no comment 8 = other, see comments CONTRALATERAL MASKING / RI: 0 = no data 1 = no 2 = partial 3 = complete 4 = unspecified amount 5 = possibly 7 = other, no comment 8 = other, see comments CRI / PRI: MM: 00 - 59 SS: 00 - 59 77 = imprecise value recorded (ie. 3 minutes +) 88 = declined to code OTHER EFFECTS: 0 = no data 1 = none 2 = tinnitus aggravated 3 = sound quality different 7 = other, no comment 8 = other, see comments
___ 26. MASKING TRIALS COMPLETED 0 = no data 1 = no trials done 2 = trials not completed (code reasons why in General ents) 3 = trials completed 4 = more than 4 trials - see patient file 7 = other, no comment 8 = other, see comments
27. CHANGE IN TINNITUS LOCATION FOLLOWING EVALUATION___________________________ describe if yes
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MASKING / RESIDUAL INHIBITION SUMMARY: MML MAXIMUM DRI TYPE ASSOCIATED ASSOCIATED (Lowest SL) MM / SS OF RI TRIAL # TRIAL #
28. RE STIM A.____ B.____/____ C.____ D.____ __
29. LE STIM A.____ B.____/____ C.____ D.____ __
TYPE OF RI:
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
ASSOCIATED TRIAL #: 0 = no data 1 = trial #1 2 = trial #2 3 = trial #3 4 = trial #4 5 = associated with more than 1 trial 7 = other, no comment 8 = other, see comments
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TINNITUS TEST RESULTS - GENERAL COMMENT FIELD COMMENTS:______________________________________________________________________ ===============================================================================