Tinnitus history form



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TINNITUS HISTORY FORM
Have you had the following:

1. excessive wax in ears Yes  No 

2. middle ear effusion (excess outpouring of fluid) Yes  No 

3. exposure to loud noise - at work Yes  No 

during recreation Yes  No 

in your living areas Yes  No 


4. blocked eustachian tube Yes  No 

5. increased tinnitus during stressful times Yes  No 

6. history of ear problems/diseases Yes  No 

what kind? ___________________________________________

7. asthma Yes  No 

8. migraine headaches Yes  No 

9. trauma to head/ear Yes  No 

10. excessive use of alcohol Yes  No 

11. smoking Yes  No 

If ‘yes’, how many? ____ cigarettes per day; Proprietary  self rolled 

Pipe smoking: __________________

Other: _________________________

12. posture / back / neck problems Yes  No 

13. Meniere’s disease (disorder of the inner ear) Yes  No 

14. thyroid disorders Yes  No 

15. cervical spondylosis Yes  No 

16. arthritis Yes  No 

17. multiple sclerosis Yes  No 

18. anaemia Yes  No 

19. STD (sexually transmitted disease) Yes  No 

20. frequent colds / viral infections Yes  No 


  1. otomastoiditis (inflammation of the mastoid Yes  No 

area behind the ear)

22. high fever Yes  No 



  1. menningitis (inflammation of the membranes that Yes  No 

surround the brain and spinal cord)

  1. viral labyrinthitis (inflammation of canals in the inner ear) Yes  No 

25. hyperlipidaemia (excessive fat in blood) Yes  No 

26. paraesthesia (abnormal numbness or pins and needles) Yes  No 

27. prolonged use of aspirin Yes  No 

28. use of quinine (malaria medication, gin & tonic) Yes  No 

29. prolonged use of antibiotics Yes  No 

30. TMD (jaw problems) Yes  No 

31. kidney problems Yes  No 

32. high blood pressure Yes  No 

33. otosclerosis (degenerative changes in the ear) Yes  No 

34. Bell’s Palsy (paralysis of the facial nerve) Yes  No 

35. tumours Yes  No 

36. Auto-immune diseases Yes  No 


Name:_______________________________________________Date:_________

Z:\Documents\dst Admin & System\New Patient Form\Tinnitus History Form



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