TINNITUS CLINIC MEDICAL AND HEALTH INFORMATION NAME___________________________________ BIRTHDATE____________________ LAST FIRST INITIAL MONTH DATE YEAR =============================================================================== 30. HAVE YOU HAD ANY OF THE FOLLOWING (CHECK ALL THAT APPLY) AGE AT AGE AT ONSET ONSET [] HEART DISEASE _______ [] ARTHRITIS OR RHEUMATISM _______ [] HIGH BLOOD PRESSURE _______ [] DIABETES _______ [] HARDENING OF ARTERIES, _______ [] THYROID PROBLEM _______ ATHEROSCLEROSIS [] KIDNEY DISEASE _______ [] VARICOSE VEINS, PHLEBITIS _______ [] CANCER _______ [] STROKE _______ [] SEVERE BURN OR WOUND _______ [] EMPHYSEMA, ASTHMA _______ [] SEVERE INFECTION _______ [] PNEUMONIA _______ [] DEPRESSION _______ [] OTHER SIGNIFICANT HEALTH PROBLEM ______________________________________ _______________________________________________________________________ _______________________________________________________________________ 31. DID YOU RECEIVE ANY MEDICATION(S) FOR CONDITIONS LISTED ABOVE APPROXIMATE DATES CONDITION MEDICATION NAME STARTED ENDED ________________________________ _____________________ ________ ________ ________________________________ _____________________ ________ ________ ________________________________ _____________________ ________ ________ ________________________________ _____________________ ________ ________ ________________________________ _____________________ ________ ________ ________________________________ _____________________ ________ ________ 32. WHAT MEDICATIONS ARE YOU TAKING CURRENTLY MEDICATION NAME AMOUNT / FREQUENCY DATE STARTED ________________________________ _____________________ _________________ ________________________________ _____________________ _________________ ________________________________ _____________________ _________________ ________________________________ _____________________ _________________ ________________________________ _____________________ _________________ 33. HAVE ANY MEDICATIONS CAUSED YOU TO EXPERIENCE CHANGES IN YOUR TINNITUS __________________________________________________________________________ __________________________________________________________________________ (PLEASE GIVE MEDICATION NAME, DESCRIBE CHANGES) 34. HAVE YOU EVER BEEN DIAGNOSED AS HAVING ANY OF THE FOLLOWING: [] NO [] YES (CHECK ALL THAT APPLY) AGE AT ONSET AGE AT ONSET [] MENIERE'S DISEASE _______ [] CHOLESTEATOMA _______ [] OTOSCLEROSIS _______ [] LABYRINTHITIS _______ [] FACIAL PAIN, NUMBNESS OR _______ [] MASTOIDITIS _______ PARALYSIS 35. HAVE YOU HAD FREQUENT OR RECURRING EARACHES OR EAR INFECTIONS? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | AGE AT FIRST OCCURRENCE:____________________________________ | | AGE AT LAST OR MOST RECENT OCCURRENCE:______________________ | | AVERAGE NUMBER OF OCCURRENCES PER YEAR:_____________________ | +--------------------------------------------------------------+ 36. HAVE YOU HAD ANY OTHER EAR PROBLEMS OR EAR INJURY? [] NO [] YES IF YES, DESCRIBE AND GIVE APPROXIMATE DATES: ____________________________ _________________________________________________________________________ 37. DO YOU EVER EXPERIENCE DIZZINESS? [] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS +--------------------------------------------------------------+ IF YES:--> | WHAT TYPE OF DIZZINESS: (CHECK ALL THAT APPLY) | | [] TURNING OR SPINNING SENSATIONS | | [] FAINTNESS OR LIGHT-HEADEDNESS | | [] LOSS OF BALANCE, FEEL YOU MAY FALL | | [] OTHER:___________________________________________________ | | DESCRIBE | | WHEN DID YOU FIRST NOTICE DIZZINESS:________________________ | | DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) | | ____________________________________________________________ | +--------------------------------------------------------------+ 38. DO YOU EXPERIENCE PAIN IN THE EAR? [] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS +--------------------------------------------------------------+ IF YES:--> | WHICH EAR(S) AFFECTED: [] LEFT [] RIGHT [] BOTH [] VARIES | | WHEN DID YOU FIRST NOTICE EAR PAIN:_________________________ | | DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) | | ____________________________________________________________ | +--------------------------------------------------------------+ 39. DO YOU EVER EXPERIENCE FEELINGS OF "FULLNESS", "PLUGGING", OR SENSATIONS OF "PRESSURE" IN THE EAR? [] RARELY / NEVER [] SOMETIMES [] MOST OF THE TIME [] ALWAYS +--------------------------------------------------------------+ IF YES:--> | WHICH EAR(S) AFFECTED: [] LEFT [] RIGHT [] BOTH [] VARIES | | WHEN DID YOU FIRST NOTICE:__________________________________ | | DO YOU KNOW OF ANYTHING THAT TRIGGERS IT: (DESCRIBE) | | ____________________________________________________________ | +--------------------------------------------------------------+ 40. HAVE YOU RECEIVED ANY MEDICATIONS FOR DIZZINESS, EAR PAIN OR EAR "FULLNESS"? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | ____________________________________________________________ | | ____________________________________________________________ | | MEDICATION NAMES APPROXIMATE DATES STARTED & STOPPED | +--------------------------------------------------------------+ 41. DID ANY OF THESE MEDICATIONS CAUSE CHANGES IN YOUR TINNITUS: [] NO [] YES +-------------------------------------------------------------------------+ | IF YES:________________________________________________________________ | | MEDICATION NAME DESCRIBE CHANGES CAUSED | +-------------------------------------------------------------------------+ 42. DO YOU HAVE ANY ALLERGIES? [] NO [] YES [] UNSURE +--------------------------------------------------------------+ IF YES:--> | (CHECK ALL THAT APPLY) [] FOOD [] POLLEN | | [] ANIMAL [] DRUGS | | [] OTHER:________________________________________________ | +--------------------------------------------------------------+ 43. HOW OFTEN DO YOU GET HEADACHES? [] RARELY OR NEVER [] SEVERAL PER MONTH [] SEVERAL PER WEEK [] DAILY 44. HAS YOUR HEADACHE FREQUENCY CHANGED SINCE YOUR TINNITUS STARTED? [] NO [] YES +-------------------------------------------------------------------------+ | IF YES:________________________________________________________________ | | DESCRIBE CHANGES | +-------------------------------------------------------------------------+ 45. IN THE PERIOD SINCE YOUR TINNITUS STARTED HAVE YOU USED ANY OF THE FOLLOWING? [] NO [] YES (IF YES, PLEASE CHECK ALL THAT APPLY & INDICATE FREQUENCY OF USE) SEVERAL SEVERAL RARELY DAILY PER WEEK PER MONTH OR NEVER [] TOBACCO IN ANY FORM _____ _____ _____ _____ [] CAFFEINE _____ _____ _____ _____ (COFFEE, TEA, COLA DRINKS) [] ALCOHOL _____ _____ _____ _____ (WINE, BEER, OR OTHER ALCOHOL) [] ASPIRIN _____ _____ _____ _____ (BUFFERIN, ANACIN, ASCRIPTIN, PLAIN ASPIRIN TABLETS, ETC.) [] TYLENOL OR OTHER PAIN KILLER _____ _____ _____ _____ IF OTHER, DESCRIBE:________________________________ 46. HAVE YOU HAD SIGNIFICANT HEAD OR NECK INJURY? [] NO [] YES +--------------------------------------------------------------+ IF YES:--> | LOCATION OF INJURY: [] HEAD [] NECK [] BOTH [] UNSURE | | DID INJURY CAUSE ANY OF THE FOLLOWING: | | [] CONCUSSION [] SKULL FRACTURE [] DIZZINESS | | [] UNCONSCIOUSNESS [] VERTEBRAL FRACTURE [] WHIPLASH | | WHEN DID INJURY OCCUR? _____________________________________ | | DID TINNITUS START AS A RESULT OF THIS INJURY? [] NO [] YES | | IF ALREADY PRESENT, DID TINNITUS CHANGE AS A RESULT OF THIS | | INJURY? [] NO [] YES _________________________________ | | DESCRIBE CHANGES | +--------------------------------------------------------------+ 47. HAVE YOU UNDERGONE SURGERY FOR ANY CONDITION? [] NO [] YES (CHECK ALL THAT APPLY) AGE AGE AGE [] TONSILS, ADENOIDS _____ [] HERNIA _____ [] HYSTERECTOMY _____ [] APPENDIX _____ [] PROSTATE _____ [] CAESAREAN SECTION _____ [] OTHER SURGERY:________________________________________________________ ______________________________________________________________________ REASON FOR SURGERY APPROX DATE(S) 48. WERE YOU EVER HOSPITALIZED FOR ANY OTHER REASON? [] NO [] YES +-------------------------------------------------------------------------+ | IF YES:________________________________________________________________ | | ________________________________________________________________ | | REASON FOR HOSPITALIZATION APPROX DATE(S) | +-------------------------------------------------------------------------+ 49. HAVE YOU HAD ANY OF THE FOLLOWING? [] NO [] YES (CHECK ALL THAT APPLY) APPROX AGE APPROX AGE [] GERMAN MEASLES ______ [] WHOOPING COUGH ______ (3-DAY, RUBELLA) ______ [] DIPHTHERIA ______ [] HARD MEASLES ______ [] MONONUCLEOSIS ______ [] MUMPS ______ [] HEPATITIS ______ [] CHICKEN POX ______ [] TUBERCULOSIS ______ [] SCARLET FEVER ______ [] SYPHILIS ______ [] RHEUMATIC FEVER ______ [] MALARIA ______ [] OTHER COMMUNICABLE DISEASES___________________________________________ 50. HAVE YOU HAD ANY PROBLEMS WITH YOUR JAW OR YOUR TEETH? [] NO [] YES (CHECK ALL THAT APPLY) AGE AT PRIOR TO CURRENT ONSET TINNITUS? PROBLEM? (YES/NO) (YES/NO) [] PAIN OR DISCOMFORT OF JAW ______ ______ ______ [] JAW INJURY, SURGERY, INFECTION ______ ______ ______ [] INCORRECT BITE OR OTHER MISALIGNMENT ______ ______ ______ [] CLICKING OR OTHER NOISE IN JAW ______ ______ ______ [] PAIN OR DISCOMFORT FROM DENTURES ______ ______ ______ [] DO YOU GRIND YOUR TEETH? ______ ______ ______ (SLEEPING OR WAKING) [] ORAL SURGERY:_________________________ ______ ______ ______ DESCRIBE [] OTHER PROBLEM OF TEETH OR JAW: ______ ______ ______ ______________________________________
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