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.
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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.
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Speech sounds muffled or indistinct
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51c.
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Difficulty hearing speech in noisy surroundings
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51d.
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Problems with telephone
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51e.
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Other problems hearing speech:________________________________
describe
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52a.
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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.
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Soft or weak sounds
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52c.
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High pitched sounds
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52d.
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Listening to radio or TV
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52e.
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Other hearing problems:_______________________________________
describe
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IF YES TO PROBLEMS HEARING SPEECH OR OTHER SOUNDS:
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53a.
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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.
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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.
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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.
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NOTICED ADDITIONAL CHANGES SINCE ONSET?
0 = no data
1 = no
2 = yes
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IF YES:____________________________________________________________
describe
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53e.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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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___________________ ___ ___ / ___ ___ / ___ ___
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B.
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___________________ ___ ___ / ___ ___ / ___ ___
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C.
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___________________ ___ ___ / ___ ___ / ___ ___
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D.
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___________________ ___ ___ / ___ ___ / ___ ___
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E.
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___________________ ___ ___ / ___ ___ / ___ ___
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F.
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___________________ ___ ___ / ___ ___ / ___ ___
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G.
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___________________ ___ ___ / ___ ___ / ___ ___
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H.
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___________________ ___ ___ / ___ ___ / ___ ___
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I.
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___________________ ___ ___ / ___ ___ / ___ ___
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J.
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___________________ ___ ___ / ___ ___ / ___ ___
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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.
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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.
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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.
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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.
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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.
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OTHER ENVIRONMENTAL HAZARDS?
0 = no data
1 = no
2 = yes, describe in comments
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62a.
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MAJOR OCCUPATION 1ST LISTED
use Occupation codes
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62b.
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MAJOR OCCUPATION 2ND LISTED
use Occupation codes
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63a.
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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.
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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.
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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.
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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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