TINNITUS DATA REGISTRY - DEMOGRAPHIC INFORMATION

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MORE THAN 42 DX'S
    (leave blank if answer is no)
    2 = yes

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CLINIC
    0 = no data
    1 = tinnitus clinic
    7 = other, no further info
    8 = other, see comments

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SEX
    0 = no data
    1 = male
    2 = female

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AGE
leave blank if age not known
    YEARS OF AGE: 01 - 99

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WEIGHT (in pounds)
leave blank if weight not known
    POUNDS: 001 - 999

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HEIGHT (in inches)
leave blank if height not known
    INCHES: 01 - 120

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EYE COLOR
    0 = no data
    1 = brown
    2 = blue
    3 = green, hazel, grey
    7 = other, no further info
    8 = other, see comments

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HAND PREFERENCE
    0 = no data
    1 = right handed
    2 = left handed
    3 = ambidextrous
    6 = unsure
    7 = other, no comment
    8 = other, see comments

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              DEMOGRAPHIC INFORMATION - GENERAL COMMENT FIELD







COMMENTS:______________________________________________________________________








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