Tinnitus & Hyperacusis Questionnaire
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- Winifred Lang
- 10 years ago
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1 Tinnitus & Hyperacusis Questionnaire Please answer the following questions and return to our office. If you need more space for an answer, write it on a separate sheet of paper and indicate the question and page number. Date: Name: Address: Phone: Cell: Fax: Date of Birth: SSN: Occupation: Insurance Company: Insurance ID#: Referred by or physician you would like copy of records sent to (complete address and zip): Name: Address: [1]
2 Medical History Current medical/health problems: Major surgery(ies) in the past: List all current medications and doses (please print) Name of drug (e.g. Aspirin) Dosage (e.g mg per day) How long (e.g. last 2 years) Indicate medication allergies: None List: List health problems that run in your family: Tobacco use: No Yes How much: Alcohol use: No Yes How much: Street drug use: No Yes How much: [2]
3 Review of Symptoms Do you have problems with any of the following? Please circle no or yes. explanation to the right. Breathing/Respiratory System NO YES Heart/Blood pressure NO YES Digestive system NO YES Urinary tract/kidney NO YES Reproductive system NO YES Bone & joint NO YES Diabetes or thyroid NO YES Skin problem NO YES Neurologic impairment/headaches NO YES Infections NO YES General (weight loss, fever) NO YES Anxiety or psychological NO YES Changes in appetite (no appetite/ravenously eating) NO YES Sleep disorder (e.g. sleep apnea) NO YES No energy/often fatigued NO YES Restless and irritable NO YES Feeling worthless, hopeless NO YES Difficulty thinking, concentrating NO YES Thoughts of death NO YES Attempts at suicide NO YES Pessimistic about life goals NO YES Chronic aches and pains NO YES If yes, please write Otologic history Do you have hearing loss? No Yes Left Right How Severe? Cause of hearing loss: Unknown Duration of hearing loss: Is your hearing changing: No Yes Progressive Fluctuating Stable Have you ever used hearing aids? No Yes How Long? [3]
4 Do you have dizziness? No Yes Is this dizziness a feeling of being light headed OR is the room/world spinning around? Is your dizziness: Constant Episodic How Frequent? Is our tinnitus related to dizziness in any way? No Yes How? Do you have a history of any of the following? Please circle no or yes. If yes please write explanation to the right. Ear infections Noise exposure Family history of hearing loss Family history of tinnitus Family history of sound intolerance Head trauma Explosive injuries to the ear Intravenous antibiotics Tinnitus questions When did you first become aware of having tinnitus? In which ear is your tinnitus? (Please circle): Right Left Both Not in ears in head If tinnitus is in both ears, is one side louder than the other? No Yes What does it sound like? (Please circle): Ringing Hissing Humming Crickets Seashell Other (please describe): Is the volume of the tinnitus stable, or does it change? Is it synchronized with your heartbeat? No Yes Does anything make your tinnitus change? No Yes (If yes, please explain): Is the tinnitus made worse by exposure to a sound? No Yes (if yes, how long does it stay worse after sound exposure): List all methods, procedures, medications, or devices you have tried for your tinnitus and the treatment outcome: Have you seen other ear specialists about your tinnitus? No Yes How Many? What were you told?: [4]
5 What tests were done by these specialists? Audiogram NO YES Date/Outcome? ABR NO YES Date/Outcome? CT Scan NO YES Date/Outcome? MRI Scan NO YES Date/Outcome? ENG NO YES Date/Outcome? Other (specify) NO YES Date/Outcome? Do you have decreased tolerance to everyday sound? No Yes When did it start? List uncomfortable sounds: Do you were ear protection (plugs or muffs)? No Yes If yes, estimate the percentage of time you wear them: Do you wear ear protection in quiet situations? No Yes List all methods, procedures, medications, or devices you have tried for your sound tolerance problems and the treatment outcome: Have you seen other ear specialists about your sound tolerance problems? No Yes How many? What were you told? Are there activities that you are prevented from doing, or are affected by the tinnitus, sound tolerance problem or hearing loss? Please check yes/no/not sure in all three categories: ACTIVITY TINNITUS SOUND TOLERANCE HEARING LOSS Concentration Falling asleep Staying asleep Restaurants Social events Church Sport events Activities in quiet Concerts other Yes No Not sure Yes No Not sure Yes No Not sure [5]
6 Have you ever worked anywhere that exposed you to continuously loud noise, such as a factory, jackhammer use, or airport? No Yes If yes, describe noise and duration of exposure: Estimate the percentage of time over a period of a month that you are in: (1.) A quiet environment (i.e.: like a quiet home, where you could speak with a soft voice and still be understood). Quiet % (2.) A moderate environment (i.e.: like an office, restaurant, out in public, where you will have to speak with a normal voice). Moderate % (3.) A loud environment (i.e. loud work place, concert, a loud radio or tv, where you would find it necessary to increase your voice to be understood). Loud % Estimate the percentage of time over the past month that you were aware of the tinnitus: % What percentage of that time did the tinnitus annoy you? % Do you feel depressed: No Yes If yes, explain why: Did you have any depression or anxiety before the onset of tinnitus or sound tolerance problems? No Yes If yes, what typically set off this depression? Do you have legal action pending in relation to your tinnitus/sound tolerance problems/hearing loss/or are you planning legal action? No Yes If yes, please explain: On a scale of 0 to 10 (0 = none; 10 = as bad as you can imagine), please indicate (circle the number value) the influence tinnitus, sound tolerance problems, and/or hearing loss have on your life: Tinnitus Sound Tolerance Problems Hearing Loss What is the greatest concern for you? Tinnitus / Sound Tolerance / Hearing Loss (please circle one) [6]
7 Please add any other information relevant to your problem(s): [7]
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NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction
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Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose