Initial Tinnitus Questionnaire Patient Name
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- Bu səhifədəki naviqasiya:
- Ear Health History
- Does your tinnitus….
- Office Use Only (2)___ (1)___ (0)___ Total_________ Sound Tolerance
- Does sound in your environment….
- Does your hearing….
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Patient Name: ______________________ _______________________________________ Date: _____________ Reason for today’s appointment: ___________________________________________________________________________________________ Allergies to any medications, plastics, etc.? __________________________________________________________________________________ Current medications: ____________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
Have you been exposed to loud sounds/noise? Yes No If yes, explain______________________________________________________ Have you ever had ear surgery? Yes No If yes, ear? Right Left type?_____________________________________ Have you ever had any head/ear trauma? Yes No If yes, explain_______________________________________________________ Have you ever taken medication that had a toxic effect on your hearing? Yes No If yes, type?_____________________________________ *Have you experienced any drainage from your ear(s) within the last 90 days? Yes No If yes, Right Left Both *Do you suffer from pain or discomfort in your ear(s)? Yes No If yes, Right Left Both Do you have temporomandibular joint (TMJ) disorder? Yes No If yes, Right Left Both Do you have a congenital or traumatic deformity of the ear? Yes No If yes, describe: ___________________________________________________________________________________________________ Do you often have significant cerumen (earwax) accumulation in your ear canal? Right Left Both Neither *Do you suffer from acute or chronic dizziness? Yes No Please list all major surgeries (Past 10 years: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Please list any serious illnesses (Past 10 years): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Are you diabetic? Yes No Do you have high blood pressure? Yes No Tinnitus Tinnitus refers to any kind of sound in your head…ringing, hissing and so on. Think only about your tinnitus in regard to the following questions…….. How does the tinnitus sound?__________________________________________________________________ Constant? Intermittent? In which ear is your tinnitus? Right Left Both Head Other How long ago did you notice the tinnitus? Recently 1-3 years 3-10 years More than 10 years Do you remember the onset of your tinnitus? Yes No Was it a sudden or progressive onset? Sudden Progressive Was it related to any other medical or environmental condition? Yes No *Does your tinnitus pulse with your heartbeat? Yes No *Is your tinnitus triggered by head or neck movement? Yes No Is there any one in your family who has/had tinnitus? Yes No Have you consulted any other professional or tried any treatment for your tinnitus? Yes No If yes, explain___________________________________________________________________________________________________________ Does your tinnitus…. Make it difficult to fall asleep? always sometimes never Make it difficult to concentrate while reading? always sometimes never Make it difficult to relax in a quiet room? always sometimes never Make it difficult to focus your attention away from your tinnitus? always sometimes never Cause you to feel angry? always sometimes never Cause you to feel stressed? always sometimes never Cause you to feel sad? always sometimes never Office Use Only (2)___ (1)___ (0)___ Total_________ Sound Tolerance Sound tolerance refers to how you react to sounds in your environment. Think only about your sound tolerance in regard to the following questions….. Do you use ear protection (earplugs or earmuffs) specifically for tinnitus? Yes No Do you have a decreased tolerance to sound (are sounds bothersome to you when they seem normal to other people around you)? Yes No
Cause an increase in your tinnitus? always sometimes never Cause you to avoid going certain places? always sometimes never Cause you to feel irritated? always sometimes never Hearing Hearing refers to your ability to detect sounds in your environment or your ability to understand the speech of other. Think only about your hearing in regard to the following questions… When was your last hearing exam? ______________________________ By whom? ________________________________________________ What were the results? _____________________________________Recommendations?_____________________________________________ Have you ever worn hearing aids? Yes No *Have you experienced a sudden hearing loss? Yes No
Limit or hamper your personal or social life? always sometimes never Cause you to hear people but not understand what they are saying? always sometimes never
If you answered “tinnitus” as your main problem… What percent of the time are you aware of it? __________ How strong, or loud was your tinnitus, on average, over the last month? “0” would be “no tinnitus and “10” would be “as loud as you can imagine.” (Severity) 0 1 2 3 4 5 6 7 8 9 10 How much has tinnitus annoyed you, on average, over the last month” “0” would be “not annoying at all” and “10” would be “as annoying as you could imagine.” (Annoyance) 0 1 2 3 4 5 6 7 8 9 10 How much did tinnitus impact your life, over the last month? “0” would be “not at all”; “10” would be “as much as you could imagine.” (Effect) 0 1 2 3 4 5 6 7 8 9 10
How do you feel about your tinnitus? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Yüklə 24,54 Kb. Dostları ilə paylaş:
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