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TINNITUS CLINIC
MEDICAL AND HEALTH INFORMATION
NAME___________________________________ BIRTHDATE____________________
LAST FIRST INITIAL MONTH DATE YEAR
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30. |
HAVE YOU HAD ANY OF THE FOLLOWING (CHECK ALL THAT APPLY)
AGE AT AGE AT
ONSET ONSET
[] HEART DISEASE _______ [] ARTHRITIS OR RHEUMATISM _______
[] HIGH BLOOD PRESSURE _______ [] DIABETES _______
[] HARDENING OF ARTERIES, _______ [] THYROID PROBLEM _______
ATHEROSCLEROSIS [] KIDNEY DISEASE _______
[] VARICOSE VEINS, PHLEBITIS _______ [] CANCER _______
[] STROKE _______ [] SEVERE BURN OR WOUND _______
[] EMPHYSEMA, ASTHMA _______ [] SEVERE INFECTION _______
[] PNEUMONIA _______ [] DEPRESSION _______
[] OTHER SIGNIFICANT HEALTH PROBLEM ______________________________________
_______________________________________________________________________
_______________________________________________________________________ |
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31. |
DID YOU RECEIVE ANY MEDICATION(S) FOR CONDITIONS LISTED ABOVE
APPROXIMATE DATES
CONDITION MEDICATION NAME STARTED ENDED
________________________________ _____________________ ________ ________
________________________________ _____________________ ________ ________
________________________________ _____________________ ________ ________
________________________________ _____________________ ________ ________
________________________________ _____________________ ________ ________
________________________________ _____________________ ________ ________ |
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32. |
WHAT MEDICATIONS ARE YOU TAKING CURRENTLY
MEDICATION NAME AMOUNT / FREQUENCY DATE STARTED
________________________________ _____________________ _________________
________________________________ _____________________ _________________
________________________________ _____________________ _________________
________________________________ _____________________ _________________
________________________________ _____________________ _________________ |
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33. |
HAVE ANY MEDICATIONS CAUSED YOU TO EXPERIENCE CHANGES IN YOUR TINNITUS
__________________________________________________________________________
__________________________________________________________________________
(PLEASE GIVE MEDICATION NAME, DESCRIBE CHANGES) |
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34. |
HAVE YOU EVER BEEN DIAGNOSED AS HAVING ANY OF THE FOLLOWING: [] NO [] YES
(CHECK ALL THAT APPLY) AGE AT ONSET AGE AT ONSET
[] MENIERE'S DISEASE _______ [] CHOLESTEATOMA _______
[] OTOSCLEROSIS _______ [] LABYRINTHITIS _______
[] FACIAL PAIN, NUMBNESS OR _______ [] MASTOIDITIS _______
PARALYSIS |
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35. |
HAVE YOU HAD FREQUENT OR RECURRING EARACHES OR EAR INFECTIONS? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | AGE AT FIRST OCCURRENCE:____________________________________ |
| AGE AT LAST OR MOST RECENT OCCURRENCE:______________________ |
| AVERAGE NUMBER OF OCCURRENCES PER YEAR:_____________________ |
+--------------------------------------------------------------+ |
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36. |
HAVE YOU HAD ANY OTHER EAR PROBLEMS OR EAR INJURY? [] NO [] YES
IF YES, DESCRIBE AND GIVE APPROXIMATE DATES: ____________________________
_________________________________________________________________________ |
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37. |
DO YOU EVER EXPERIENCE DIZZINESS?
[] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS
+--------------------------------------------------------------+
IF YES:--> | WHAT TYPE OF DIZZINESS: (CHECK ALL THAT APPLY) |
| [] TURNING OR SPINNING SENSATIONS |
| [] FAINTNESS OR LIGHT-HEADEDNESS |
| [] LOSS OF BALANCE, FEEL YOU MAY FALL |
| [] OTHER:___________________________________________________ |
| DESCRIBE |
| WHEN DID YOU FIRST NOTICE DIZZINESS:________________________ |
| DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) |
| ____________________________________________________________ |
+--------------------------------------------------------------+ |
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38. |
DO YOU EXPERIENCE PAIN IN THE EAR?
[] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS
+--------------------------------------------------------------+
IF YES:--> | WHICH EAR(S) AFFECTED: [] LEFT [] RIGHT [] BOTH [] VARIES |
| WHEN DID YOU FIRST NOTICE EAR PAIN:_________________________ |
| DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) |
| ____________________________________________________________ |
+--------------------------------------------------------------+ |
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39. |
DO YOU EVER EXPERIENCE FEELINGS OF "FULLNESS", "PLUGGING", OR SENSATIONS OF
"PRESSURE" IN THE EAR?
[] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS
+--------------------------------------------------------------+
IF YES:--> | WHICH EAR(S) AFFECTED: [] LEFT [] RIGHT [] BOTH [] VARIES |
| WHEN DID YOU FIRST NOTICE:__________________________________ |
| DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) |
| ____________________________________________________________ |
+--------------------------------------------------------------+ |
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40. |
HAVE YOU RECEIVED ANY MEDICATIONS FOR DIZZINESS, EAR PAIN OR EAR
"FULLNESS"? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | ____________________________________________________________ |
| ____________________________________________________________ |
| MEDICATION NAMES APPROXIMATE DATES STARTED & STOPPED |
+--------------------------------------------------------------+ |
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41. |
DID ANY OF THESE MEDICATIONS CAUSE CHANGES IN YOUR TINNITUS: [] NO [] YES
+-------------------------------------------------------------------------+
| IF YES:________________________________________________________________ |
| MEDICATION NAME DESCRIBE CHANGES CAUSED |
+-------------------------------------------------------------------------+ |
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42. |
DO YOU HAVE ANY ALLERGIES? [] NO [] YES [] UNSURE
+--------------------------------------------------------------+
IF YES:--> | (CHECK ALL THAT APPLY) [] FOOD [] POLLEN |
| [] ANIMAL [] DRUGS |
| [] OTHER:________________________________________________ |
+--------------------------------------------------------------+ |
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43. |
HOW OFTEN DO YOU GET HEADACHES?
[] RARELY OR NEVER [] SEVERAL PER MONTH [] SEVERAL PER WEEK [] DAILY |
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44. |
HAS YOUR HEADACHE FREQUENCY CHANGED SINCE YOUR TINNITUS STARTED?
[] NO [] YES
+-------------------------------------------------------------------------+
| IF YES:________________________________________________________________ |
| DESCRIBE CHANGES |
+-------------------------------------------------------------------------+ |
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45. |
IN THE PERIOD SINCE YOUR TINNITUS STARTED HAVE YOU USED ANY OF THE
FOLLOWING? [] NO [] YES
(IF YES, PLEASE CHECK ALL THAT APPLY & INDICATE FREQUENCY OF USE)
SEVERAL SEVERAL RARELY
DAILY PER WEEK PER MONTH OR NEVER
[] TOBACCO IN ANY FORM _____ _____ _____ _____
[] CAFFEINE _____ _____ _____ _____
(COFFEE, TEA, COLA DRINKS)
[] ALCOHOL _____ _____ _____ _____
(WINE, BEER, OR OTHER ALCOHOL)
[] ASPIRIN _____ _____ _____ _____
(BUFFERIN, ANACIN, ASCRIPTIN,
PLAIN ASPIRIN TABLETS, ETC.)
[] TYLENOL OR OTHER PAIN KILLER _____ _____ _____ _____
IF OTHER, DESCRIBE:________________________________ |
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46. |
HAVE YOU HAD SIGNIFICANT HEAD OR NECK INJURY? [] NO [] YES
+--------------------------------------------------------------+
IF YES:--> | LOCATION OF INJURY: [] HEAD [] NECK [] BOTH [] UNSURE |
| DID INJURY CAUSE ANY OF THE FOLLOWING: |
| [] CONCUSSION [] SKULL FRACTURE [] DIZZINESS |
| [] UNCONSCIOUSNESS [] VERTEBRAL FRACTURE [] WHIPLASH |
| WHEN DID INJURY OCCUR? _____________________________________ |
| DID TINNITUS START AS A RESULT OF THIS INJURY? [] NO [] YES |
| IF ALREADY PRESENT, DID TINNITUS CHANGE AS A RESULT OF THIS |
| INJURY? [] NO [] YES _________________________________ |
| DESCRIBE CHANGES |
+--------------------------------------------------------------+ |
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47. |
HAVE YOU UNDERGONE SURGERY FOR ANY CONDITION? [] NO [] YES
(CHECK ALL THAT APPLY) AGE AGE AGE
[] TONSILS, ADENOIDS _____ [] HERNIA _____ [] HYSTERECTOMY _____
[] APPENDIX _____ [] PROSTATE _____ [] CAESAREAN SECTION _____
[] OTHER SURGERY:________________________________________________________
______________________________________________________________________
REASON FOR SURGERY APPROX DATE(S) |
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48. |
WERE YOU EVER HOSPITALIZED FOR ANY OTHER REASON? [] NO [] YES
+-------------------------------------------------------------------------+
| IF YES:________________________________________________________________ |
| ________________________________________________________________ |
| REASON FOR HOSPITALIZATION APPROX DATE(S) |
+-------------------------------------------------------------------------+ |
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49. |
HAVE YOU HAD ANY OF THE FOLLOWING? [] NO [] YES
(CHECK ALL THAT APPLY)
APPROX AGE APPROX AGE
[] GERMAN MEASLES ______ [] WHOOPING COUGH ______
(3-DAY, RUBELLA) ______ [] DIPHTHERIA ______
[] HARD MEASLES ______ [] MONONUCLEOSIS ______
[] MUMPS ______ [] HEPATITIS ______
[] CHICKEN POX ______ [] TUBERCULOSIS ______
[] SCARLET FEVER ______ [] SYPHILIS ______
[] RHEUMATIC FEVER ______ [] MALARIA ______
[] OTHER COMMUNICABLE DISEASES___________________________________________ |
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50. |
HAVE YOU HAD ANY PROBLEMS WITH YOUR JAW OR YOUR TEETH? [] NO [] YES
(CHECK ALL THAT APPLY) AGE AT PRIOR TO CURRENT
ONSET TINNITUS? PROBLEM?
(YES/NO) (YES/NO)
[] PAIN OR DISCOMFORT OF JAW ______ ______ ______
[] JAW INJURY, SURGERY, INFECTION ______ ______ ______
[] INCORRECT BITE OR OTHER MISALIGNMENT ______ ______ ______
[] CLICKING OR OTHER NOISE IN JAW ______ ______ ______
[] PAIN OR DISCOMFORT FROM DENTURES ______ ______ ______
[] DO YOU GRIND YOUR TEETH? ______ ______ ______
(SLEEPING OR WAKING)
[] ORAL SURGERY:_________________________ ______ ______ ______
DESCRIBE
[] OTHER PROBLEM OF TEETH OR JAW: ______ ______ ______
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