Patient Name: _____________________________________________________________ Date: _____________
Reason for today’s appointment: ___________________________________________________________________________________________
Allergies to any medications, plastics, etc.? __________________________________________________________________________________
Current medications: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Ear Health History
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
Does sound in your environment….
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
Does your hearing….
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
What do you consider is your main problem? Hearing Tinnitus Sound tolerance
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
Have you experienced any stressful events within the last 12 months? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How do you feel about your tinnitus?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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