TINNITUS CLINIC TINNITUS DESCRIPTION AND HISTORY NAME___________________________________ AGE______ BIRTHDATE____________________ LAST FIRST INITIAL MONTH DATE YEAR ADDRESS__________________________________________ PHONE________________________ HOME _________________________________________________ ________________________ CITY STATE ZIP CODE WORK WHAT IS YOUR HEIGHT:______ WEIGHT:_____ EYE COLOR:_____ RIGHT OR LEFT HANDED? (CIRCLE ONE) REFERRED TO TINNITUS CLINIC BY:________________________________________________ NAME LOCATION =============================================================================== 1. WHEN DID YOU BECOME AWARE OF HAVING TINNITUS (NOISE OR SOUNDS IN YOUR EARS OR HEAD)?__________________________________________________________________ 2. DID YOU BECOME AWARE OF YOUR TINNITUS SUDDENLY OR GRADUALLY? ______________ 3. BEFORE THAT DID YOU EXPERIENCE ANY EPISODES OF TEMPORARY OR MILDER TINNITUS? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | (CHECK ALL THAT APPLY IN THE LIST BELOW) | | | | [] AFTER EXPOSURE TO LOUD SOUND | | [] ASSOCIATED WITH COLDS, FLU, OR ALLERGY | | PROBLEM | | [] ANY OTHER TIME(S)________________________________________ | | DESCRIBE | +--------------------------------------------------------------+ 4. HOW LONG HAS TINNITUS BEEN A SIGNIFICANT PROBLEM FOR__________________ 5. WERE ILLNESS, ACCIDENT OR OTHER SPECIAL CIRCUMSTANCES ASSOCIATED WITH THE ONSET OF YOUR PRESENT TINNITUS? ___________________________________________ ___________________________________________________________________________ PLEASE EXPLAIN BRIEFLY 6. DOES YOUR TINNITUS CONSIST OF ONE SOUND OR MORE THAN ONE SOUND? ___________ 7. IN THE LIST BELOW, PLEASE CHECK SOUND(S) THAT MOST CLOSELY RESEMBLE YOUR TINNITUS: [] RINGING [] HISSING [] SIZZLING [] PULSATING [] CLEAR TONE [] BUZZING [] TRANSFORMER NOISE [] POUNDING [] MORE THAN ONE TONE [] HUM [] HIGH TENSION WIRE [] OCEAN ROAR [] WHISTLE [] MUSIC [] CRICKETS, INSECTS [] CLICKING [] OTHER: _________________________________________________________________ DESCRIBE HAS YOUR TINNITUS SOUNDED ABOUT THE SAME (IN TERMS OF TYPE OF SOUND) SINCE IT FIRST STARTED, OR HAS THE TYPE OF SOUND CHANGED? _______________________ DESCRIBE CHANGE(S) IF ANY 8. IF YOU HEAR MORE THAN ONE SOUND, WHICH SOUND IS PREDOMINANT OR MOST BOTHERSOME? _______________________________________________________________ 9. WHERE DOES YOUR PREDOMINANT TINNITUS SOUND APPEAR TO BE COMING FROM? ___________________________________________________________________________ IF IN MORE THAN ONE LOCATION, WHERE IS IT WORST: __________________________ 10. IF YOU DO HEAR OTHER TINNITUS SOUNDS BESIDES THE PREDOMINANT ONE, PLEASE DESCRIBE: TYPE OF SOUND LOCATION SOUND #2 IS:_____________________, APPEARS TO BE LOCATED IN:_______________ SOUND #3 IS:_____________________, APPEARS TO BE LOCATED IN:_______________ DO YOU HEAR ANY ADDITIONAL SOUNDS NOT ALREADY DESCRIBED? [] NO [] YES ___________________________________________________________________________ INDICATE TYPE OF SOUND AND WHERE LOCATED 11. DO YOU HEAR YOUR PREDOMINANT TINNITUS SOUND ALL THE TIME OR IS IT SOMETIMES ABSENT? [] HEARD ALL THE TIME [] SOMETIMES ABSENT:____________________________ APPROXIMATE PERCENT OF TIME HEARD SINCE YOUR TINNITUS STARTED, HAS IT ALTERED IN REGARD TO THE PERCENT OF TIME HEARD? [] NO CHANGE [] YES, PERCENT OF TIME HAS CHANGED [] NOT SURE +-------------------------------------------------------------+ IF YES:--> | [] I NOW HEAR TINNITUS MORE OF THE TIME THAN AT FIRST | | [] I NOW HEAR TINNITUS LESS OF THE TIME THAN AT FIRST | +-------------------------------------------------------------+ 12. SINCE IT STARTED HAS THE LOCATION OF YOUR TINNITUS CHANGED? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | PLEASE DESCRIBE CHANGES:____________________________________ | | WERE CHANGES RELATED TO ILLNESS, ACCIDENT, OR OTHER EVENT? | | ____________________________________________________________ | | IF YES, DESCRIBE BRIEFLY | +--------------------------------------------------------------+ 13. SINCE IT STARTED HAS THE LOUDNESS OF YOUR TINNITUS CHANGED? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | HAS IT GROWN: [] LOUDER [] SOFTER | | [] BOTH TYPES OF CHANGE OCCURRED | | WERE CHANGES RELATED TO ILLNESS, ACCIDENT, OR OTHER EVENT? | | ____________________________________________________________ | | IF YES, DESCRIBE BRIEFLY | +--------------------------------------------------------------+ 14. DOES THE LOUDNESS OF YOUR TINNITUS TEND TO FLUCTUATE UP AND DOWN? [] NO [] YES +-------------------------------------------------------------+ IF YES:--> | INDICATE SIZE OF FLUCTUATIONS: [] BARELY NOTICEABLE | | [] MODERATE | | [] VERY MARKED | | [] VARIABLE IN SIZE | | HOW OFTEN DO FLUCTUATIONS OCCUR? | | [] DAILY [] SEVERAL PER WEEK | | [] SEVERAL PER MONTH [] RARELY | +-------------------------------------------------------------+ 15. ON THE SCALE BELOW PLEASE INDICATE THE LOUDNESS OF YOUR USUAL TINNITUS (CIRCLE NUMBER) 0 1 2 3 4 5 6 7 8 9 10 _______________________________________________________________________ VERY QUIET INTERMEDIATE LOUDNESS VERY LOUD 16. HAVE YOU NOTICED CHANGES IN TINNITUS LOUDNESS CAUSED BY ANY OF THE FOLLOWING: (CHECK ALL THAT APPLY & INDICATE WHETHER THEY MAKE TINNITUS LOUDER OR SOFTER) [] TOBACCO USE _______________ [] MARIJUANA _______________ [] ALCOHOLIC BEVERAGES _______________ [] CAFFEINE (COFFEE, TEA, COLA, ETC) _______________ [] ASPIRIN _______________ [] TYLENOL, OTHER PAIN-KILLER _______________ [] NO, NONE OF THE ABOVE ALTERS MY TINNITUS 17. HAVE YOU NOTICED CHANGES IN TINNITUS LOUDNESS CAUSED BY ANY OF THE FOLLOWING: (CHECK ALL THAT APPLY & INDICATE WHETHER THEY MAKE TINNITUS LOUDER OR SOFTER) [] NOISE EXPOSURE _______________ [] STRESS OR FATIGUE _______________ [] COLDS, SINUS, HAYFEVER _______________ [] COUGHING OR SNEEZING _______________ [] MOVING JAW, CLENCHING TEETH _______________ [] CHANGES IN ALTITUDE _______________ [] ALTERATIONS IN BODY POSITION _______________ [] NO, NONE OF THE ABOVE ALTERS MY TINNITUS 18. IS THERE ANYTHING ELSE THAT YOU HAVE NOTICED CAUSES CHANGES IN YOUR TINNITUS? ___________________________________________________________________________ INDICATE AGENT CAUSING CHANGE INDICATE NATURE OF CHANGE 19. DOES YOUR TINNITUS INTERFERE WITH SLEEP? [] NO [] YES, SOMETIMES [] YES, OFTEN +--------------------------------------------------------------+ IF YES:--> | TYPE OF INTERFERENCE: [] TROUBLE GETTING TO SLEEP | | [] TROUBLE STAYING ASLEEP | | [] OTHER____________________________ | | HOW SEVERE IS PROBLEM: [] MILD [] MODERATE [] SEVERE | +--------------------------------------------------------------+ HAVE YOU FOUND ANYTHING THAT HELPS YOU SLEEP:______________________________ DESCRIBE 20. DO YOU FEEL TINNITUS HAS CAUSED YOU SIGNIFICANT PROBLEMS IN ANY OF THESE WAYS: MAKES YOU FEEL IRRITABLE OR NERVOUS [] NO [] SOMETIMES [] YES MAKES YOU FEEL TIRED OR ILL [] NO [] SOMETIMES [] YES MAKES IT DIFFICULT TO RELAX [] NO [] SOMETIMES [] YES 21. HAS TINNITUS CAUSED YOU ANY OF THE FOLLOWING PROBLEMS: MADE IT UNCOMFORTABLE TO BE IN QUIET [] NO [] SOMETIMES [] YES MADE IT DIFFICULT TO CONCENTRATE [] NO [] SOMETIMES [] YES MADE IT HARDER TO INTERACT PLEASANTLY [] NO [] SOMETIMES [] YES WITH OTHERS 22. ANY OTHER PROBLEMS TINNITUS HAS CAUSED YOU: (A) AT WORK:______________________________________________________________ DESCRIBE PROBLEM (B) AT HOME OR IN LEISURE TIME:___________________________________________ ___________________________________________________________________________ DESCRIBE PROBLEM 23. HAVE YOU CHANGED JOBS BECAUSE OF TINNITUS? [] NO [] YES:_________________ ___________________________________________________________________________ EXPLAIN CHANGE 24. HAVE YOU MADE OTHER SIGNIFICANT CHANGES IN YOUR LIFESTYLE BECAUSE OF TINNITUS? [] NO [] YES:_______________________________________________ EXPLAIN 25. HOW MUCH OF AN EFFORT IS IT FOR YOU TO IGNORE YOUR TINNITUS WHEN IT IS PRESENT? [] CAN EASILY IGNORE IT [] CAN IGNORE IT WITH SOME EFFORT [] IT TAKES CONSIDERABLE EFFORT TO IGNORE IT [] CAN NEVER IGNORE IT 26. HOW MUCH DISCOMFORT DO YOU USUALLY EXPERIENCE WHEN YOUR TINNITUS IS PRESENT? [] NO DISCOMFORT [] MODERATE DISCOMFORT [] MILD DISCOMFORT [] A GREAT DEAL OF DISCOMFORT 27. HOW MUCH INTERFERENCE DOES TINNITUS CAUSE YOU FOR THE FOLLOWING ACTIVITIES? NONE SLIGHT MODERATE A GREAT DEAL OF INTERFERENCE INTERFERENCE INTERFERENCE A. WORK ACTIVITIES ______ ______ ______ ______ B. SOCIAL ACTIVITIES ______ ______ ______ ______ C. OVERALL ENJOYMENT ______ ______ ______ ______ 28. HAVE YOU PREVIOUSLY SOUGHT MEDICAL HELP FOR YOUR TINNITUS? [] NO [] YES ___________________________________________________________________________ ___________________________________________________________________________ IF YES, PLEASE INDICATE WHERE AND WHEN 29. HAVE YOU PREVIOUSLY TRIED ANY OF THE FOLLOWING TYPES OF TREATMENT FOR TINNITUS? +------------------------------------------------------+ [] NO [] YES:--> | AMOUNT | | DATES OF RELIEF | | [] BIOFEEDBACK _______ _______ | | [] DRUG THERAPY:_________________ _______ _______ | | DESCRIBE | | [] MASKING _______ _______ | | [] HYPNOSIS OR ACUPUNCTURE _______ _______ | | [] OTHER:________________________ _______ _______ | | DESCRIBE | +------------------------------------------------------+
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