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
area behind the ear) 22. high fever Yes No
surround the brain and spinal cord)
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:_________ Yüklə 9,42 Kb. Dostları ilə paylaş:
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