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
-
otomastoiditis (inflammation of the mastoid Yes No
area behind the ear)
22. high fever Yes No
-
menningitis (inflammation of the membranes that Yes No
surround the brain and spinal cord)
-
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:_________
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