TinniTus INTAKE FORM - widexpro.com
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Daytime phone: Home phone:
• Whendidyoufirstexperiencetinnitus?
• Howlonghaveyouhadtinnitusinitspresentform?yearsmonths
• Brieflydescribewhatyouweredoingwhenthetinnitusfirstbecameapparenttoyou:
• Wereyouexperiencinganykindofemotionaltraumaatthetimewhenyoufirstnoticedyourtinnitus?
•Whatdoyouthinkisthecauseofyourtinnitus?
• Whereisyourtinnitusprimarilylocated?
Leftear Rightear Bothearsequally Head
Other(pleaseexplain):
• Usingthescalebelow,indicatetheLOUDNESSof:
A)Yourtinnitusrightnow B)Youraveragetinnitus
C)Yourtinnitusatitsworst D)Yourtinnitusatitsleast
0 1 2 3 4 5 6 7 8 9 10None Mild Moderate SevereExcruciating
Name:Age:Date://
Referredby:
TinniTus INTAKE FORM
1/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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• Usingthescalebelow,indicatethePITCHofyourtinnitus: (Itmighthelptoimaginethescaleasifitwereapianokeyboard.)
0 1 2 3 4 5 6 7 8 9 10Lowpitch MidpitchHighpitch
• Theloudnessofyourtinnitusis(checkone):
fairlyconstantfromdaytoday
fluctuateswidely,beingveryloudsomedaysandverymildotherdays
usuallyconstant,butoccasionallydecreasesmarkedly
usuallyconstant,butoccasionallyincreasesmarkedly
• Doesyourtinnitusappearworse:
whentired whentenseornervous
atbedtime afteruseofalcohol
uponawakening whenrelaxed
• Checkallitemsbelowwhichdescribethesoundofyourtinnitus:
Hissing Ringing Cricket-like Whistle
Steamwhistle Pounding Pulsating Bells
Clanging Buzzing Sizzling Ticking
Oceanroar Hightensionwire Other:
• Towhatextentareyoubotheredorannoyedbyyourtinnitus?
0 1 2 3 4 5 6 7 8 9 10Notbothered Mild Moderate SevereExtreme
2/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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• Whenareyouawareofyourtinnitus?
• Whatpercentageofthetimeareyoubotheredbyyourtinnitus?
• Isthereanytimeduringthedaywhenyourtinnitusismosttroublesometoyou?
Atwork Inmorning
Inevening Whentryingtoconcentrate
Atsocialactivities Aroundnoise
Other:
• Doyouconsideryourselftobeatenseperson?
• Doyoufeelthatemotionalorphysicalstressworsensthetinnitus?
• Pleasetellushowyourtinnitusinterfereswithyouractivities:
Concentration
Work/Chores
Family
Religiousactivities
Social/Recreation
Exercise
Sleep
• Doesthetinnituspreventyoufromfallingasleep?
• Doesthetinnitusawakenyoufromsleep?
• Areyouabletofallbackasleep,onceawakened?
Other:
3/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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• Doyouhaveahearingloss?YesNo
• Whichismoreofaproblemforyou,thehearingdifficultyoryourtinnitus?
Hearingdifficulty Tinnitus Notsure
• Haveyoubeenexposedtoloudnoise?YesNo
Ifso,when?MilitaryserviceWorkRecreation
Other:
• Doyouwearearprotectioninthepresenceofloudsounds?
YesNo
• Haveyoueverwornahearingaid?YesNo
Ifyes,doyoucurrentlywearit(them)?YesNo
• Ifyouareahearingaiduser,howdoestheaidaffectyourtinnitus?
MakestinnitussofterMakestinnituslouderNoeffect
• Areyouadverselyaffectedbyloudsounds?YesNo
Pleaseexplain:
• Howwouldyourlifebedifferentifyoudidn’thavetinnitus?
• Haveyoudiscussedyourtinnituswithfriendsorfamilymembers?YesNo
Whatwastheirreaction?
• Arethereothermembersofyourfamilyorfriendswhosufferfromtinnitus?YesNo
• Doyoulivealone?YesNo
4/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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TREATMENT HISTORY• Pleaselistallevaluationsand/ortreatments(includingpsychiatricorpsychologic)youhavehadforyour tinnitus.Pleaseincludethenamesofthespecialistswhohaveperformedevaluationsortreatments,and theapproximatedatesonwhichtheywereperformed,usingthereverseside,ifnecessary.
Provider Whatwasdone? Date Result
1.
2.
3.
4.
5.
• Pleaselistanysurgeriesyouhavehad(potentiallyrelatedtoyourcurrentsymptomoftinnitus):
• Pleaselistthemedicationsyouarecurrentlytakingfortinnitus:
Medication Dose Howoften? Doesithelp? Doctor
YesNo
YesNo
YesNo
YesNo
• Whatothermedicationshaveyoutriedinthepastfortinnitusrelief?
Medication Dose Howoften? Doesithelp? Stopped(Why?)
YesNo
YesNo
YesNo
YesNo
5/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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• Pleaselistallothermedicationsyoucurrentlytake:
Medication Dose Howoften? Purpose? Doctor
• Usingthenumbercodesbelow,pleaseindicatetheresultsofthosetreatmentsyouhavetriedforyour tinnitus.Ifyouhavenottriedagiventreatment,pleaseplacean“NA”intheblankforthattreatment.
1=Majorrelief 2=Somerelief 3=Norelief 4=Somereliefwithbadsideeffects 5=Tinnitusworse NA=Notapplicable,treatmentnottried
Surgery Acupuncture
Drugtherapy Massage
Hearingaids Homeopathy
Maskingtherapy Biofeedback
Physicaltherapy Chiropractic
Antidepressants Relaxationtrainingorhypnosis
Exerciseprogram Psychotherapyorothercounseling
Dental DietaryManagementornutritioncounseling
Other:
• Areyouemployed? No.ofhoursperweek
• Whatisyouroccupation?
• Areyousatisfied?
• Ifnotemployed,isyourunemploymentduetotinnitus?
6/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.
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• Doyouhaveanyear,noseorthroatdiseases?
• Doyouhaveanyotherdiseasesthataffectyouinyourdailylife?
• Anyotherissuesyouwouldlikeustoknowabout?
7/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.