TINNITUS DATA REGISTRY - TINNITUS TEST RESULTS
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FINAL BEST MATCH:
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PREDOMINANCE
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FREQUENCY (Hz) SL dB MATCHED TO
LOW / HIGH RE STIM LE STIM SOUND TYPE(S) LOCATION(S)
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1a.
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_______ / _______ ____ ____ ____ ____ ____ ________
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____
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1b.
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_______ / _______ ____ ____ ____ ____ ____ ________
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____
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1c.
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_______ / _______ ____ ____ ____ ____ ____ ________
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____
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1d.
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_______ / _______ ____ ____ ____ ____ ____ ________
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SL dB:
88 = could not achieve loudness match
90 = SL dB known but stim location is not
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SOUND TYPE:
0 = no data
1 = ringing
2 = clear tone
3 = more than 1 tone
4 = whistle
5 = hissing
6 = buzzing
7 = hum
8 = music
9 = sizzling
10 = transformer noise
11 = hi tension wire
12 = crickets
13 = pulsating
14 = pounding
15 = ocean roar
16 = clicking
77 = other, no comment
88 = other, see General Comment Field for appropriate form
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LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form
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1e.
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EXAMINERS CONFIDENCE IN PITCH MATCH
0 = no data
1 = good
2 = fair
3 = poor
8 = other, see comments
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2.
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EXAMINER
use examiner codes
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3.
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ARE THERE OTHER SOUNDS BESIDES THOSE MATCHED?
0 = no data
1 = no
2 = yes
3 = unsure
7 = other, no comment
8 = other, see comments
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GENERAL DESCRIPTION OF TINNITUS (AT THE BEGINNING OF THE TEST):
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16.
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TINNITUS TODAY TYPICAL
0 = no data
1 = no, no further info
2 = yes
3 = sound quality different
4 = louder, more intense
5 = softer, less intense
7 = other, no comment
8 = other, see comments
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17.
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LOCATION WHERE WORST
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable locations
15 = both ears
17 = not sure of location
77 = other, no comment
88 = other, see comments
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18.
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EVIDENCE OF PULSATION
0 = no data
1 = no
2 = yes
7 = other, no comment
8 = other, see comments
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TINNITUS MATCHING:
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19.
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LOCATION BEING MATCHED
use location codes
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LOCATION:
use code 15 for both ears, not codes 1 and 5.
0 = no data
1 = left ear
2 = in head, left
3 = outside head, left
4 = not sure, left
5 = right ear
6 = in head, right
7 = outside head, right
8 = not sure, right
9 = fills head
10 = inside, top of head
11 = outside, top of head
12 = surrounds head
13 = back of head
14 = variable location
15 = both ears
17 = not sure of location
77 = other, no comments
88 = other, see General Comment Field for appropriate form
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20.
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STIMULUS TYPE
0 = no data
1 = pure tone
2 = narrow band noise
3 = wide band noise
4 = crickets
5 = tone + noise
7 = other, no comment
8 = other, see comments
9 = too complex to code
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21.
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TYPE OF EQUIPMENT
0 = no data
1 = tinnitus synthesizer 1
2 = tinnitus synthesizer 2
3 = tinnitus synthesizer 3
4 = tinnitus synthesizer 4
7 = other, no comment
8 = other, see comments
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FREQUENCY (Hz) RIGHT EAR LEFT EAR
THRESHOLD LOUDNESS STIM THRESHOLD LOUDNESS STIM
MATCH dBSL MATCH dBSL
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22a.
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250 ____ ____ ____ ____ ____ ____
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22b.
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500 ____ ____ ____ ____ ____ ____
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22c.
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1000 ____ ____ ____ ____ ____ ____
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22d.
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2000 ____ ____ ____ ____ ____ ____
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22e.
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3000 ____ ____ ____ ____ ____ ____
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22g.
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5000 ____ ____ ____ ____ ____ ____
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22h.
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6000 ____ ____ ____ ____ ____ ____
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22i.
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7000 ____ ____ ____ ____ ____ ____
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22j.
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8000 ____ ____ ____ ____ ____ ____
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22k.
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9000 ____ ____ ____ ____ ____ ____
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22l.
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10000 ____ ____ ____ ____ ____ ____
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22m.
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11000 ____ ____ ____ ____ ____ ____
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22n.
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12000 ____ ____ ____ ____ ____ ____
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OTHERS:
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22o.
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___ / ___ ____ ____ ____ ____ ____ ____
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22p.
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___ / ___ ____ ____ ____ ____ ____ ____
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22q.
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___ / ___ ____ ____ ____ ____ ____ ____
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STIM dBSL:
88 = could not achieve loudness match
90 = too complex to code
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23.
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MATCHING TEST COMPLETED
0 = no data
1 = no attempts made
2 = test not completed
3 = test complete
7 = other, no comment
8 = other, see comments
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24.
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OCTAVE CONFUSION
0 = no data
1 = no
2 = yes
3 = did not test for
7 = other, no comment
8 = other, see comments
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25.
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TINNITUS MASKING AND RESIDUAL INHIBITION TRIALS:
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TRIAL# 1.FREQUENCY (Hz) 2.STIM 3.STIM 4.AMT OF 5.CONTRALATERAL 6.OTHER
low / high EAR SL MASKING MASKING? EFFECTS
A.____ ____ / ____ ____ ____ ____ ____ ____
7.RI STIM 8.CRI 9.PRI 10.CONTRALATERAL 11.OTHER
SL MM/SS MM/SS RI? EFFECTS
____ __/__ __/__ ____ ____
B.____ ____ __/__ __/__ ____ ____
____ __/__ __/__ ____ ____
C.____ ____ __/__ __/__ ____ ____
____ __/__ __/__ ____ ____
D.____ ____ __/__ __/__ ____ ____
____ __/__ __/__ ____ ____
STIM EAR:
0 = no data
1 = left ear
2 = right ear
3 = both ears
STIM SL:
dB SL: 00 - 79, or:
88 = could not mask at limits of equipment
90 = too complex to code
AMT OF MASKING:
0 = no data
1 = none
2 = partial
3 = complete
7 = other, no comment
8 = other, see comments
CONTRALATERAL MASKING / RI:
0 = no data
1 = no
2 = partial
3 = complete
4 = unspecified amount
5 = possibly
7 = other, no comment
8 = other, see comments
CRI / PRI:
MM: 00 - 59
SS: 00 - 59
77 = imprecise value recorded (ie. 3 minutes +)
88 = declined to code
OTHER EFFECTS:
0 = no data
1 = none
2 = tinnitus aggravated
3 = sound quality different
7 = other, no comment
8 = other, see comments
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26.
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MASKING TRIALS COMPLETED
0 = no data
1 = no trials done
2 = trials not completed (code reasons why in General ents)
3 = trials completed
4 = more than 4 trials - see patient file
7 = other, no comment
8 = other, see comments
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27.
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CHANGE IN TINNITUS LOCATION FOLLOWING EVALUATION___________________________
describe if yes
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MASKING / RESIDUAL INHIBITION SUMMARY:
MML MAXIMUM DRI TYPE ASSOCIATED ASSOCIATED
(Lowest SL) MM / SS OF RI TRIAL # TRIAL #
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28.
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RE STIM A.____ B.____/____ C.____ D.____ __
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29.
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LE STIM A.____ B.____/____ C.____ D.____ __
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TYPE OF RI:
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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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ASSOCIATED TRIAL #:
0 = no data
1 = trial #1
2 = trial #2
3 = trial #3
4 = trial #4
5 = associated with more than 1 trial
7 = other, no comment
8 = other, see comments
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TINNITUS TEST RESULTS - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
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