TINNITUS CLINIC HEARING HISTORY AND OCCUPATIONAL EXPOSURE NAME___________________________________ BIRTHDATE_____________________ LAST FIRST INITIAL MONTH DATE YEAR =============================================================================== 51. DO YOU HAVE ANY DIFFICULTIES HEARING SPEECH? [] NO [] YES, SOMETIMES [] YES, OFTEN +-------------------------------------------------------------+ IF YES:--> | (PLEASE DESCRIBE THE TYPES OF DIFFICULTIES YOU ARE HAVING) | | [] SPEECH SOUNDS MUFFLED OR INDISTINCT AT TIMES | | ________________________________________________________ | | [] HAVE DIFFICULTY HEARING SPEECH IN NOISY SURROUNDINGS | | ________________________________________________________ | | [] HAVE SOME PROBLEMS USING TELEPHONE | | ________________________________________________________ | | [] OTHER PROBLEM(S) HEARING SPEECH:________________________ | | ________________________________________________________ | +-------------------------------------------------------------+ 52. DO YOU HAVE ANY PROBLEMS HEARING OTHER TYPES OF SOUNDS? [] NO [] YES, SOMETIMES [] YES, OFTEN +-------------------------------------------------------------+ IF YES:--> | (PLEASE DESCRIBE PROBLEMS) | | [] TROUBLE HEARING SOFT OR WEAK SOUNDS | | ________________________________________________________ | | [] TROUBLE HEARING HIGH-PITCHED SOUNDS | | ________________________________________________________ | | [] TROUBLE LISTENING TO RADIO OR TV | | ________________________________________________________ | | [] OTHER HEARING PROBLEM(S):_______________________________ | | ________________________________________________________ | +-------------------------------------------------------------+ 53. IF YOU DO NOTICE PROBLEMS HEARING SPEECH OR OTHER TYPES OF SOUND, PLEASE ANSWER THE FOLLOWING: +-------------------------------------------------------------------------+ | (A) WHICH EAR(S) ARE AFFECTED: [] LEFT EAR [] RIGHT EAR | | [] BOTH [] UNSURE | | (B) WHEN DID YOU FIRST NOTICE CHANGES IN YOUR HEARING ABILITY? | | ___________________________________________________________________ | | (C) WAS THE ONSET OF THESE HEARING CHANGES GRADUAL OR SUDDEN: | | ___________________________________________________________________ | | (D) IF SUDDEN, WAS HEARING CHANGE ASSOCIATED WITH ILLNESS, ACCIDENT OR | | OTHER SPECIAL CIRCUMSTANCES:_______________________________________ | | PLEASE EXPLAIN BRIEFLY | +-------------------------------------------------------------------------+ 54. DOES YOUR HEARING ABILITY FOR SPEECH OR OTHER SOUNDS SEEM TO FLUCTUATE FROM DAY TO DAY? [] NO [] YES [] UNSURE +-------------------------------------------------------------+ IF YES:--> | ARE FLUCTUATIONS RELATED TO ANY OF THE FOLLOWING: | | (CHECK ALL THAT APPLY) | | [] FLUCTUATIONS IN TINNITUS LOUDNESS | | [] FEELINGS OF "FULLNESS" OR "PRESSURE" IN EARS | | [] CHANGES IN YOUR HEALTH:_________________________________ | | DESCRIBE | | [] OTHER:__________________________________________________ | | DESCRIBE | +-------------------------------------------------------------+ 55. DO YOU FIND LOUD SOUNDS MORE UNPLEASANT THAN YOU USED TO? [] NO [] YES [] UNSURE +-------------------------------------------------------------+ IF YES:--> | DID THIS CHANGE OCCUR: APPROXIMATE DATE OF CHANGE | | [] BEFORE YOU WERE AWARE OF HEARING TINNITUS ______________ | | [] AFTER YOU BECAME AWARE OF TINNITUS ______________ | | [] ABOUT THE SAME TIME YOU NOTICED TINNITUS ______________ | | [] NOT SURE WHEN CHANGE OCCURRED ______________ | +-------------------------------------------------------------+ 56. HAVE YOU WORKED IN ANY OF THE FOLLOWING TYPES OF OCCUPATIONS? [] NO [] YES +-------------------------------------------------------------------------+ | (IF YES, CHECK ALL THAT APPLY, EVEN IF VERY BRIEF) APPROX | | STARTING LENGTH | | AGE OF TIME | | [] LOGGING, LUMBER INDUSTRY ________ ________ | | [] MINING ________ ________ | | [] FARMING ________ ________ | | [] FACTORY:_______________________________________ ________ ________ | | INDICATE TYPE | | [] CANNERY ________ ________ | | [] PRINTING ________ ________ | | [] TRANSPORTATION (TRUCK, BOAT, PLANE, ETC.) ________ ________ | | [] CONSTRUCTION: _________________________________ ________ ________ | | INDICATE TYPE | | [] POLICE, FIRE DEPT. ________ ________ | | [] LOUD MUSIC (1) AMPLIFIED ( ROCK BAND, OTHER ) ________ ________ | | (2) LIVE MUSIC ________ ________ | | [] ANY OTHER TYPES OF NOISY OCCUPATION (DESCRIBE) | | ______________________________________________ ________ ________ | | ______________________________________________ ________ ________ | +-------------------------------------------------------------------------+ 57. HAVE YOU BEEN IN MILITARY SERVICE? [] NO [] YES +-------------------------------------------------------------------------+ | (IF YES, CHECK ALL THAT APPLY, EVEN IF VERY BRIEF) APPROX | | STARTING LENGTH | | AGE OF TIME | | [] ARTILLERY ________ ________ | | [] TANKS, OTHER HEAVY EQUIPMENT ________ ________ | | [] PLANES, HELICOPTERS ________ ________ | | [] SMALL ARMS (1) BASIC TRAINING ________ ________ | | (2) AFTER BASIC ________ ________ | | [] EXPLOSION ________ ________ | | [] OTHER:_________________________________________ ________ ________ | +-------------------------------------------------------------------------+ 58. HAVE YOU BEEN EXPOSED TO NOISE DURING RECREATIONAL OR LEISURE-TIME ACTIVITIES? [] NO [] YES IF YES: +-------------------------------------------------------------------------+ | (PLEASE CHECK ALL THAT APPLY TO YOU IN THE LIST BELOW, | | EVEN IF YOU DID THEM ONLY A FEW TIMES OR A LONG TIME AGO) APPROX | | STARTING LENGTH | | AGE OF TIME | | [] GUNFIRE _______________________________________ ________ ________ | | INDICATE TYPE(S) | | [] POWER TOOLS ___________________________________ ________ ________ | | INDICATE TYPE(S) | | [] ENGINES (BOAT, AUTO, MOTORCYCLE, SKIMOBILE) ________ ________ | | [] LOUD MUSIC ________ ________ | | [] OTHER:_________________________________________ ________ ________ | | DESCRIBE | +-------------------------------------------------------------------------+ 59. HAVE YOU UNDERGONE ANY ACCIDENTAL EXPOSURE TO SUDDEN, INTENSE NOISE? [] NO [] YES IF YES:__________________________________ _______________ _______________ TYPE OF NOISE WHICH EAR OR YOUR AGE THEN SIDE OF HEAD 60. HAVE YOU EVER WORKED IN A JOB THAT BROUGHT YOU IN CONTACT WITH TOXIC OR HAZARDOUS CHEMICALS? [] NO [] NOT SURE [] YES IF YES: +-------------------------------------------------------------------------+ | (PLEASE CHECK ALL THAT APPLY BELOW) DURATION OF EXPOSURE | | & APPROX DATES | | [] DRY CLEANING & RELATED CHEMICALS ________________________________ | | [] PAINT, LACQUER, RELATED SOLVENTS ________________________________ | | [] INSECTICIDES, DEFOLIANTS ________________________________ | | [] CHEMICAL LABORATORY (DESCRIBE TYPE) | | _______________________________ ________________________________ | | [] OTHER HAZARDOUS CHEMICALS (DESCRIBE TYPE) | | _______________________________ ________________________________ | +-------------------------------------------------------------------------+ 61. HAVE YOU BEEN EXPOSED TO ANY OTHER ENVIRONMENTAL HAZARDS (EITHER AT WORK OR AWAY FROM WORK) THAT YOU FEEL MAY BE RELATED TO PROBLEMS WITH HEARING OR TINNITUS? [] NO [] YES:_________________________________________________________ ________________________________________________________ IF YES, DESCRIBE 62. IN GENERAL, WHAT HAS BEEN YOUR MAJOR OCCUPATION DURING YOUR WORKING HOURS SO FAR? ___________________________________________________________________ INDICATE JOB OR JOBS YOU HELD LONGEST 63. HAVE YOU EVER WORN A HEARING AID? [] NO [] YES +-------------------------------------------------------------+ IF YES:--> | EAR OR EARS: [] LEFT [] RIGHT [] BOTH EARS | | MAKE & MODEL (IF KNOWN):___________________________________ | | WHEN DID YOU FIRST OBTAIN:_________________________________ | | HOW LONG DID YOU USE:______________________________________ | | HOW HELPFUL WAS THE HEARING AMPLIFICATION:_________________ | | ___________________________________________________________ | | DID THE AID AFFECT YOUR TINNITUS IN ANY WAY? (DESCRIBE) | | ___________________________________________________________ | +-------------------------------------------------------------+ 64. WHICH IS MORE OF A PROBLEM FOR YOU, HEARING DIFFICULTY OR TINNITUS? [] HEARING DIFFICULTY [] TINNITUS [] THEY'RE EQUALLY BOTHERSOME [] NOT SURE 65. HAVE ANY OF YOUR BLOOD RELATIVES HAD PROBLEMS WITH HEARING OR TINNITUS? [] NO [] NOT SURE [] YES:________________________________________ ________________________________________ ________________________________________ INDICATE NATURE OF PROBLEM(S) & RELATIONSHIP TO YOU
Oregon Health & Science University. All rights reserved. Tinnitus Archive, second
edition. Website published by the Oregon Hearing Research Center.