TINNITUS DATA REGISTRY - TINNITUS RECOMMENDATIONS
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CONCLUSIONS AND RECOMMENDATIONS:
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4.
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EXAMINER
use examiner codes
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RIGHT LEFT BINAURAL
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5a.
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EFFECT OF MASKERS
0 = no data
1 = no effect
2 = partial
3 = complete
7 = other, no comment
8 = other, see comments
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5b.
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EQUIPMENT USED FOR THIS EFFECT?
use equipment table
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____ ____ ____
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5c.
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EASE OF MASKING
0 = no data
1 = masking not accomplished
2 = low levels
3 = medium level
4 = high levels
7 = other, no comment
8 = other, see comments
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6a.
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EFFECT OF AMPLIFICATION ALONE
see codes for 5A
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____ ____ ____
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6b.
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EQUIPMENT USED FOR THIS EFFECT?
use equipment table
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____ ____ ____
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6c.
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EASE OF MASKING
see codes for 5C
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____ ____ ____
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7a.
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EFFECT OF TINNITUS INSTRUMENT
see codes for 5A
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7b.
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EQUIPMENT USED FOR THIS EFFECT?
use equipment table
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____ ____ ____
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7c.
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EASE OF MASKING
see codes for 5C
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____ ____ ____
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8.
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EQUIPMENT PRODUCING MOST EFFECTIVE MASKING
use equipment table
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9.
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RESIDUAL INHIBITION BY EAR LEVEL EQUIPMENT
use residual inhibition codes
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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
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10a.
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MASKING PROGRAM BENEFIT THIS PATIENT
0 = no data
1 = no
2 = yes
7 = other, no comment
8 = other, see comments
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IF NO:
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10b.
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REASON(S) WHY
0 = no data
1 = could not mask effectively, no further info
2 = tinnitus is not severe enough / not enough of a problem
3 = patient prefers tinnitus to masking sound
4 = patient is not ready to participate in a masking program
at this time
5 = intensity necessary for masking is too high
6 = could not mask due to hearing loss
7 = possible medical problem, patient will seek consultation
before considering masking program
8 = masking aggravates tinnitus
77 = other, no comment
88 = other, see comments
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11a.
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MASKING AND/OR HEARING AID RECOMMENDED?
0 = no data
1 = no
2 = yes
3 = yes, hearing aid only
4 = yes, HA + TM or TI
7 = other, no comment
8 = other, see comments
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use equipment table
leave blank if not applicable
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11b.
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RIGHT EAR
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11c.
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LEFT EAR
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12a.
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PATIENT INTERESTED IN MASKING PROGRAM?
0 = no data
1 = no
2 = yes
3 = waiting for authorization
4 = cannot afford
7 = other, no comment
8 = other, see comments
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12b.
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REASON(S) WHY:
see codes for 10B
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13.
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OTHER RECOMMENDATIONS MADE
0 = no data
1 = no other recommendation
2 = medical referral
3 = dental referral
4 = hearing conservation (ear protection, avoid loud sounds)
5 = biofeedback / stress management
6 = electrical stimulation
7 = FM masking at home
8 = Custom tape (excludes OHRC tape)
9 = OHRC masking tape
77 = other, no comment
88 = other, see comments
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14.
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PATIENT REFERRED TO
use referral codes
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15.
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TIME INTERVAL PATIENT ASKED TO REPORT BACK
0 = no data
1 = not asked to report back
2 = < 1 mo
3 = 1 - 3 mos
4 = more than 3 mos, less than 6 mos
5 = more than 6 mo, less than 1 yr
6 = more than 1 yr
7 = if tinnitus worsens
77 = other, no comment
88 = other, see comments
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TINNITUS EVALUATION RESULTS - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
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