TINNITUS CLINIC
HEARING HISTORY AND OCCUPATIONAL EXPOSURE
NAME___________________________________ BIRTHDATE_____________________
LAST FIRST INITIAL MONTH DATE YEAR
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51. |
DO YOU HAVE ANY DIFFICULTIES HEARING SPEECH?
[] NO [] YES, SOMETIMES [] YES, OFTEN
+-------------------------------------------------------------+
IF YES:--> | (PLEASE DESCRIBE THE TYPES OF DIFFICULTIES YOU ARE HAVING) |
| [] SPEECH SOUNDS MUFFLED OR INDISTINCT AT TIMES |
| ________________________________________________________ |
| [] HAVE DIFFICULTY HEARING SPEECH IN NOISY SURROUNDINGS |
| ________________________________________________________ |
| [] HAVE SOME PROBLEMS USING TELEPHONE |
| ________________________________________________________ |
| [] OTHER PROBLEM(S) HEARING SPEECH:________________________ |
| ________________________________________________________ |
+-------------------------------------------------------------+ |
52. |
DO YOU HAVE ANY PROBLEMS HEARING OTHER TYPES OF SOUNDS?
[] NO [] YES, SOMETIMES [] YES, OFTEN
+-------------------------------------------------------------+
IF YES:--> | (PLEASE DESCRIBE PROBLEMS) |
| [] TROUBLE HEARING SOFT OR WEAK SOUNDS |
| ________________________________________________________ |
| [] TROUBLE HEARING HIGH-PITCHED SOUNDS |
| ________________________________________________________ |
| [] TROUBLE LISTENING TO RADIO OR TV |
| ________________________________________________________ |
| [] OTHER HEARING PROBLEM(S):_______________________________ |
| ________________________________________________________ |
+-------------------------------------------------------------+ |
53. |
IF YOU DO NOTICE PROBLEMS HEARING SPEECH OR OTHER TYPES OF SOUND, PLEASE
ANSWER THE FOLLOWING:
+-------------------------------------------------------------------------+
| (A) WHICH EAR(S) ARE AFFECTED: [] LEFT EAR [] RIGHT EAR |
| [] BOTH [] UNSURE |
| (B) WHEN DID YOU FIRST NOTICE CHANGES IN YOUR HEARING ABILITY? |
| ___________________________________________________________________ |
| (C) WAS THE ONSET OF THESE HEARING CHANGES GRADUAL OR SUDDEN: |
| ___________________________________________________________________ |
| (D) IF SUDDEN, WAS HEARING CHANGE ASSOCIATED WITH ILLNESS, ACCIDENT OR |
| OTHER SPECIAL CIRCUMSTANCES:_______________________________________ |
| PLEASE EXPLAIN BRIEFLY |
+-------------------------------------------------------------------------+ |
54. |
DOES YOUR HEARING ABILITY FOR SPEECH OR OTHER SOUNDS SEEM TO FLUCTUATE FROM
DAY TO DAY? [] NO [] YES [] UNSURE
+-------------------------------------------------------------+
IF YES:--> | ARE FLUCTUATIONS RELATED TO ANY OF THE FOLLOWING: |
| (CHECK ALL THAT APPLY) |
| [] FLUCTUATIONS IN TINNITUS LOUDNESS |
| [] FEELINGS OF "FULLNESS" OR "PRESSURE" IN EARS |
| [] CHANGES IN YOUR HEALTH:_________________________________ |
| DESCRIBE |
| [] OTHER:__________________________________________________ |
| DESCRIBE |
+-------------------------------------------------------------+ |
55. |
DO YOU FIND LOUD SOUNDS MORE UNPLEASANT THAN YOU USED TO?
[] NO [] YES [] UNSURE
+-------------------------------------------------------------+
IF YES:--> | DID THIS CHANGE OCCUR: APPROXIMATE DATE OF CHANGE |
| [] BEFORE YOU WERE AWARE OF HEARING TINNITUS ______________ |
| [] AFTER YOU BECAME AWARE OF TINNITUS ______________ |
| [] ABOUT THE SAME TIME YOU NOTICED TINNITUS ______________ |
| [] NOT SURE WHEN CHANGE OCCURRED ______________ |
+-------------------------------------------------------------+ |
56. |
HAVE YOU WORKED IN ANY OF THE FOLLOWING TYPES OF OCCUPATIONS? [] NO [] YES
+-------------------------------------------------------------------------+
| (IF YES, CHECK ALL THAT APPLY, EVEN IF VERY BRIEF) APPROX |
| STARTING LENGTH |
| AGE OF TIME |
| [] LOGGING, LUMBER INDUSTRY ________ ________ |
| [] MINING ________ ________ |
| [] FARMING ________ ________ |
| [] FACTORY:_______________________________________ ________ ________ |
| INDICATE TYPE |
| [] CANNERY ________ ________ |
| [] PRINTING ________ ________ |
| [] TRANSPORTATION (TRUCK, BOAT, PLANE, ETC.) ________ ________ |
| [] CONSTRUCTION: _________________________________ ________ ________ |
| INDICATE TYPE |
| [] POLICE, FIRE DEPT. ________ ________ |
| [] LOUD MUSIC (1) AMPLIFIED ( ROCK BAND, OTHER ) ________ ________ |
| (2) LIVE MUSIC ________ ________ |
| [] ANY OTHER TYPES OF NOISY OCCUPATION (DESCRIBE) |
| ______________________________________________ ________ ________ |
| ______________________________________________ ________ ________ |
+-------------------------------------------------------------------------+ |
57. |
HAVE YOU BEEN IN MILITARY SERVICE? [] NO [] YES
+-------------------------------------------------------------------------+
| (IF YES, CHECK ALL THAT APPLY, EVEN IF VERY BRIEF) APPROX |
| STARTING LENGTH |
| AGE OF TIME |
| [] ARTILLERY ________ ________ |
| [] TANKS, OTHER HEAVY EQUIPMENT ________ ________ |
| [] PLANES, HELICOPTERS ________ ________ |
| [] SMALL ARMS (1) BASIC TRAINING ________ ________ |
| (2) AFTER BASIC ________ ________ |
| [] EXPLOSION ________ ________ |
| [] OTHER:_________________________________________ ________ ________ |
+-------------------------------------------------------------------------+ |
58. |
HAVE YOU BEEN EXPOSED TO NOISE DURING RECREATIONAL OR LEISURE-TIME
ACTIVITIES? [] NO [] YES
IF YES:
+-------------------------------------------------------------------------+
| (PLEASE CHECK ALL THAT APPLY TO YOU IN THE LIST BELOW, |
| EVEN IF YOU DID THEM ONLY A FEW TIMES OR A LONG TIME AGO) APPROX |
| STARTING LENGTH |
| AGE OF TIME |
| [] GUNFIRE _______________________________________ ________ ________ |
| INDICATE TYPE(S) |
| [] POWER TOOLS ___________________________________ ________ ________ |
| INDICATE TYPE(S) |
| [] ENGINES (BOAT, AUTO, MOTORCYCLE, SKIMOBILE) ________ ________ |
| [] LOUD MUSIC ________ ________ |
| [] OTHER:_________________________________________ ________ ________ |
| DESCRIBE |
+-------------------------------------------------------------------------+ |
59. |
HAVE YOU UNDERGONE ANY ACCIDENTAL EXPOSURE TO SUDDEN, INTENSE NOISE?
[] NO [] YES
IF YES:__________________________________ _______________ _______________
TYPE OF NOISE WHICH EAR OR YOUR AGE THEN
SIDE OF HEAD |
60. |
HAVE YOU EVER WORKED IN A JOB THAT BROUGHT YOU IN CONTACT WITH TOXIC OR
HAZARDOUS CHEMICALS? [] NO [] NOT SURE [] YES
IF YES:
+-------------------------------------------------------------------------+
| (PLEASE CHECK ALL THAT APPLY BELOW) DURATION OF EXPOSURE |
| & APPROX DATES |
| [] DRY CLEANING & RELATED CHEMICALS ________________________________ |
| [] PAINT, LACQUER, RELATED SOLVENTS ________________________________ |
| [] INSECTICIDES, DEFOLIANTS ________________________________ |
| [] CHEMICAL LABORATORY (DESCRIBE TYPE) |
| _______________________________ ________________________________ |
| [] OTHER HAZARDOUS CHEMICALS (DESCRIBE TYPE) |
| _______________________________ ________________________________ |
+-------------------------------------------------------------------------+ |
61. |
HAVE YOU BEEN EXPOSED TO ANY OTHER ENVIRONMENTAL HAZARDS (EITHER AT WORK OR
AWAY FROM WORK) THAT YOU FEEL MAY BE RELATED TO PROBLEMS WITH HEARING OR
TINNITUS?
[] NO [] YES:_________________________________________________________
________________________________________________________
IF YES, DESCRIBE |
62. |
IN GENERAL, WHAT HAS BEEN YOUR MAJOR OCCUPATION DURING YOUR WORKING HOURS
SO FAR? ___________________________________________________________________
INDICATE JOB OR JOBS YOU HELD LONGEST |
63. |
HAVE YOU EVER WORN A HEARING AID? [] NO [] YES
+-------------------------------------------------------------+
IF YES:--> | EAR OR EARS: [] LEFT [] RIGHT [] BOTH EARS |
| MAKE & MODEL (IF KNOWN):___________________________________ |
| WHEN DID YOU FIRST OBTAIN:_________________________________ |
| HOW LONG DID YOU USE:______________________________________ |
| HOW HELPFUL WAS THE HEARING AMPLIFICATION:_________________ |
| ___________________________________________________________ |
| DID THE AID AFFECT YOUR TINNITUS IN ANY WAY? (DESCRIBE) |
| ___________________________________________________________ |
+-------------------------------------------------------------+ |
64. |
WHICH IS MORE OF A PROBLEM FOR YOU, HEARING DIFFICULTY OR TINNITUS?
[] HEARING DIFFICULTY
[] TINNITUS
[] THEY'RE EQUALLY BOTHERSOME
[] NOT SURE |
65. |
HAVE ANY OF YOUR BLOOD RELATIVES HAD PROBLEMS WITH HEARING OR TINNITUS?
[] NO [] NOT SURE [] YES:________________________________________
________________________________________
________________________________________
INDICATE NATURE OF PROBLEM(S)
& RELATIONSHIP TO YOU |