TINNITUS DATA REGISTRY - MEDICAL HISTORY
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MEDICAL HISTORY RELIABILITY
0 = no data
1 = good
2 = fair
3 = poor
8 = other, see comments
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30 - 33.
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Code illnesses and / or treatments on DX coding form
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34 - 36.
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EAR PROBLEMS OR INJURIES
0 = no data
1 = no
2 = yes, no further info
3 = yes, on DX coding form
7 = other, no comment
8 = other, see comments
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37a.
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DIZZINESS
use Frequency codes
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FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form
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IF YES:
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37b.
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DIZZINESS TYPE
0 = no data
1 = turning or spinning
2 = faintness or light headedness
3 = loss of balance, feel may fall
7 = other, no comment
8 = other, see comments
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37c.
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FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data
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37d.
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ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes
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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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37e.
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RELATED TO TINNITUS CHANGES
0 = no data
1 = no changes
2 = yes, tinnitus is louder
3 = yes, tinnitus is softer
4 = yes, changes in tinnitus sound
5 = yes, no further info
7 = other, no comment
8 = other, see comments
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37f.
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SEVERITY OF PROBLEM
0 = no data
1 = mild
2 = moderate
3 = severe
4 = patient unsure
7 = other, no comment
8 = other, see comments
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38a.
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PAIN IN THE EAR
use Frequency codes
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FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form
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IF YES:
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38b.
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EAR(S) AFFECTED
0 = no data
1 = left
2 = right
3 = both
4 = varies
7 = other, no comment
8 = other, see comments
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38c.
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FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data
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38d.
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ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes
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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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38e.
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RELATED TO TINNITUS CHANGES
use codes for Q37e
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38f.
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SEVERITY OF PROBLEM
use codes for Q37f
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39a.
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FULLNESS IN THE EAR
use Frequency codes
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FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form
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IF YES:
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39b.
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EAR(S) AFFECTED
0 = no data
1 = left
2 = right
3 = both
4 = varies
7 = other, no comment
8 = other, see comments
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39c.
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FIRST NOTICED
leave blank if date not available
MONTH: 1 - 12
YEAR: 1 - 99
0 / 0 = no data
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39d.
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ANYTHING THAT TRIGGERS
see Onset associations / Symptoms codes
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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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39e.
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RELATED TO TINNITUS CHANGES
use codes for Q37e
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39f.
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SEVERITY OF PROBLEM
use codes for Q37f
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40 - 41.
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Code medications for dizziness, ear pain and ear fullness
on DX coding form
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42.
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ALLERGIES:
0 = no data
1 = no
2 = yes
3 = formerly
6 = not sure
7 = other, no comment
8 = other, see comments
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A.
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FOOD
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B.
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POLLEN
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C.
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ANIMAL
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D.
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DRUGS
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E.
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OTHER:_________________________________________________________
describe
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43.
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HEADACHES
use Frequency codes
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FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = sometimes
3 = most of the time
4 = always
5 = yes, no further info
6 = in past only
7 = other, no comment
8 = other, see General Comment Field for appropriate form
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44.
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HEADACHE FREQUENCY CHANGE
0 = no data
1 = no change
2 = yes, less frequent
3 = yes, more frequent
5 = yes, no info on change
6 = not sure
7 = other, no comment
8 = other, see comments
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45.
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FREQUENCY OF (following):
use Frequency codes
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FREQUENCY OF OCCURRENCE:
0 = no data
1 = rarely / never
2 = several per month
3 = several per week
4 = daily
5 = yes, no info on amount
6 = patient not sure
7 = other, no comment
8 = other, see General Comment Field for appropriate form
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45a.
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TOBACCO USE
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45b.
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CAFFEINE USE
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45c.
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ALCOHOL USE
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45d.
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ASPIRIN USE
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45e.
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TYLENOL OR OTHER PAIN KILLER USE:_____________________________
describe
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46a.
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SIGNIFICANT HEAD / NECK INJURY
0 = no data
1 = no
2 = head injury
3 = neck injury
4 = head and neck injuries
5 = unsure of location
7 = other, no further info
8 = other, see comments
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IF YES:
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46b.
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MULTIPLE INJURIES
head injury = 854000
neck injury = 847000
both, unsure, no data = 849000
0 = no data
1 = one
2 = two
3 = three
4 = four
5 = > 4
6 = not sure how many
7 = other, no comment
8 = other, see comments
CODE HEAD AND / OR NECK INJURIES ON DX CODING FORM
If surgeries or treatments related to surgeries are associated with
tinnitus, code on DX coding for
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47.
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NON SIGNIFICANT SURGERIES:
(code age at onset)
YEARS: 1 - 97, or
98 = had surgery more than once, code on DX ng form
leave blank if not applicable or no data
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A.
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Tonsils / Adenoids
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B.
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Appendix
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C.
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Hernia
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D.
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Prostate
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E.
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Hysterectomy
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F.
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Caesarean Section
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G.
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Other:_______________________________________
describe
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48.
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Code other hospitalizations and associated
illnesses / treatments on DX coding form
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49.
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PAST COMMUNICABLE DISEASES
If disease occurred after age 21 and / or treatment of disease
are associated with tinnitus, code on DX coding form
0 = no data
1 = German Measles
2 = Hard Measles
3 = Unspecified Measles
4 = Mumps
5 = Chicken Pox
6 = Scarlet Fever
7 = Rheumatic Fever
8 = Whooping Cough
leave blank if not applicable
**CODE Diphtheria, Mononucleosis, Hepatitis, Tuberculosis,
Syphilis and Malaria on DX coding form
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50a.
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PROBLEMS WITH JAW OR TEETH
0 = no data
1 = no
2 = yes
3 = patient unsure
7 = other, no comment
8 = other, see comments
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IF YES:
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Age at Prior to Current
onset Tinnitus Problem
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50b.
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Pain or discomfort of jaw _____ _____ _____
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50c.
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Jaw injury, surgery, infection _____ _____ _____
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50d.
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Incorrect bite or other misalignment _____ _____ _____
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50e.
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Clicking or other noise in jaw _____ _____ _____
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50f.
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Pain or discomfort from dentures _____ _____ _____
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50g.
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Grinding of teeth _____ _____ _____
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50h.
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Oral surgery _____ _____ _____
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50i.
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Other problem of teeth or jaw _____ _____ _____
_____________________________
describe
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Age at onset:
leave blank if not applicable
YEARS: 01 - 97; 00 = no data
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Prior to Tinnitus/Current Problem:
leave blank if not applicable
0 = no data
1 = no
2 = yes
3 = unsure
8 = other, see comments
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MEDICAL HISTORY - GENERAL COMMENT FIELD
COMMENTS:______________________________________________________________________
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END OF MEDICAL HISTORY CODING FORM
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