Tinnitus, Hypo-Hyperacusis Questionnaire
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1 40, 1 er boulevard Terrasse-Vaudreuil (Québec) J7V 5S5 Phone.: (514) Fax: (514) centredacouphene@bellnet.ca Name: Address: Date of birth: Phone number: Tinnitus, Hypo-Hyperacusis Questionnaire I thank you for taking the time to fill out this questionnaire. Your answers and comments will provide me with a greater understanding of your tinnitus / hypoacusis / hyperacusis and help me to develop a more effective and holistic approach in the management of your symptom(s). This questionnaire is an adaptation of the Tinnitus Management Clinic of the Ottawa Hospital s, General Campus, questionnaire. PLEASE NOTE: This questionnaire can be completed on line, sensitive cases gray, and returned by . You can also print out the questionnaire (ideally on both sides) complete it and either post it, fax it or bring it with you the day of your appointment. To complete this questionnaire on line, follow these instructions. To write an answer, place the cursor in the gray zone and write your answer. To select a box, place the cursor in the appropriate one and click with the mouse. PART I: SYMPTOMS INVESTIGATION 1. For how long have you had? Hypoacusis: hearing loss Hyperacusis: noise sensitivity (If never, write 0 and ignore this column (If never, write 0 and ignore this column of part I) of part I) Tinnitus: sound/noise heard in one or both ear(s) or in the head (If never, write 0 and ignore this column of part I) For most of the following questions, please answer by darkening or selecting the corresponding choices. 2. How would you define your symptom? I occasionally, ask people repeat what I am sensitive to the sound of a fan they say I am sensitive to noise when I am in a I can t hear whispering very well car I increase the TV s volume I am sensitive to household noise I encounter difficulties communicating I am sensitive to noise at work with others in restaurants or during I am sensitive to loud music meetings. I am sensitive to noises in restaurants I don t understand sermons at church very well I argue with members of my family I avoid being in groups situations Clink crunch Ocean static Engine noise Buzz murmur Pounding hammering pulse Bell ring tone Running water Cicada cricket locust Whistling steam whistle Sizzling (frying) High tension electric cables Electric chocks in the head Music Voices
2 3. How did your symptom arise? Gradually in the right ear Gradually in the left ear Suddenly in the right ear Suddenly in the left ear Both ears unequally, worse in: Gradually in the right ear Gradually in the left ear Suddenly in the right ear Suddenly in the left ear Both ears unequally, worse in: Gradually in the right ear Gradually in the left ear Suddenly in the right ear Suddenly in the left ear Both ears unequally, worse in: Inside your head Outside your head 4. Evaluate your symptom with the following scale, 0=absent, 1= minor, 2= moderate, 3= severe. 5. How would you describe the severity of each of your symptoms? A little embarrassing - frustrating Slightly sensitive Occasionally embarrassing - frustrating Occasionally sensitive Often embarrassing - frustrating Often sensitive Always embarrassing - frustrating Always sensitive I isolate myself from others I can t go out without protective device Present not disturbing Disturbing but I can ignore it Hard to ignore Always disturbing Almost always intrusive Do you wear hearing aids? No Yes, right ear Yes, left ear If yes, what is your level of discomfort? 6. Since the beginning, how would you define the progression of each of your symptoms? Absent Absent Better Better Absent Better For the pitch: Lower Higher For the intensity: Less
3 7. If it fluctuates indicate for each of the following items, those that make your symptoms appear better (+) or worse (-). When I m rested (in the morning) When I m tired (at night) When I m sleeping/resting/falling asleep When I m angry When I m happy, calm When I m tense or anxious When I wear hearing aids When I wear ear protectors When I hear static noise on the radio or when I wear a masking device When I m in quiet places When I m exposed to low noise When I m exposed to loud noise When I listen to the radio, the TV or to music When doing physical activities, moving my head A change in altitude When I take medication When I drink alcohol When I m rested (in the morning) When I m tired (at night) When I m sleeping/resting/falling asleep When I m angry When I m happy, calm When I m tense or anxious When I wear hearing aids When I wear ear protectors When I hear static noise on the radio or when I wear a masking device When I m in quiet places When I m exposed to low noise When I m exposed to loud noise When I listen to the radio, the TV or to music When doing physical activities, moving my head A change in altitude When I take medication When I drink alcohol When I drink coffee, tea, cola soft drinks or chocolate beverage During my menstruation (for women) When I m active When I m rested (in the morning) When I m tired (at night) When I m sleeping/resting/falling asleep When I m angry When I m happy, calm When I m tense or anxious When I wear hearing aids When I wear ear protectors When I hear static noise on the radio or when I wear a masking device When I m in quiet places When I m exposed to low noise When I m exposed to loud noise When I listen to the radio, the TV or to music When doing physical activities, moving my head A change in altitude When I take medication When I drink alcohol When I drink coffee, tea, cola soft drinks, energy dink or chocolate beverage During my menstruation (for women) When I m active 8. Can you relate any specific event to the onset of your hypoacusis / hyperacusis / tinnitus? An ear/sinus infection A long exposure to noise Head injury Exposure to a short loud noise Whiplash - cervical trauma A disease A surgery No special event An ear/sinus infection A long exposure to noise Head injury Exposure to a short loud noise Whiplash - cervical trauma A disease A surgery No special event An ear/sinus infection A long exposure to noise Head injury Exposure to a short loud noise Whiplash - cervical trauma A disease A surgery No special event
4 9. Which one of the following medical health professionals have you consulted regarding your hypoacusis / hyperacusis / tinnitus? None General practitioner ENT specialist Audiologist Hearing aid dealer Neurologist Dentist/ TMJ specialist Psychologist/psychiatrist Chiropractor Physiotherapist Osteopath Pharmacist Naturopath None General practitioner ENT specialist Audiologist Hearing aid dealer Neurologist Dentist/ TMJ specialist Psychologist/psychiatrist Chiropractor Physiotherapist Osteopath None General practitioner ENT specialist Audiologist Hearing aid dealer Neurologist Dentist/ TMJ specialist Psychologist/psychiatrist Chiropractor Physiotherapist Osteopath Massage therapist Naturopath Dietician Pharmacist 10. For each of the following treatments that you have tried, indicate their effectiveness on each of your symptoms by (-1) if it got worst, (0) if you have noticed no improvement, (1) if it got slightly better and (2) if it eliminates your symptom. Hearing aids Deafening device Ear protectors Vitamins/diet Acupuncture Chiropractic Physiotherapy Relaxation Hearing aids Deafening device Ear protectors Vitamins/diet Acupuncture Chiropractic Physiotherapy Relaxation Biofeedback Hypnosis Psychotherapy Electric stimulation Hearing aids Deafening device Ear protectors Vitamins/diet Acupuncture Chiropractic Physiotherapy Relaxation Biofeedback Hypnosis Psychotherapy Electric stimulation 11. For each of your symptoms, indicate its interference using the following scale: 0=never, 1=sometimes, 2=often, 3=always With my personal life (happiness) With my family life Whit my social life With my work With my mental process (reading, concentration) With my sleep With my personal life (happiness) With my family life Whit my social life With my work With my mental process (reading, concentration) With my sleep With my personal life (happiness) With my family life Whit my social life With my work With my mental process (reading, concentration) With my sleep 12. Indicate your average hours of sleep per night:
5 13. If your quality of sleep is affected, describe the effect of each symptom? It takes longer to fall asleep It wakes me up when I m asleep It s not linked to my hypoacusis It takes longer to fall asleep It wakes me up when I m asleep It s not linked to my hyperacusis It takes longer to fall asleep It wakes me up when I m asleep It s not linked to my tinnitus PART II: HEARING AND GENERAL HEALTH HISTORY: Please consider all of the choices by darkening or selecting the appropriate answers and give the requested information. 14. Are you susceptible to ear-related problems? No If yes, indicate which ones: Ear infection Perforation Drainage Pain 15 Has anyone in your family ever had a hearing problem before age 50? No Yes, relation: 16.a) Have you ever been exposed to loud noises? No If yes Explain: How many years: Ear protection? b) Do you actually work in a noisy environment? No If yes Explain: How many years: Ear protection? c) Do you practice noisy hobbies (target range shooting, hunting, carpentry...)? No If yes Which one: How many years: Ear protection? d) Have you ever played music regularly? No If yes Which one: How many years: Ear protection (ER)? 17. Do you suffer from TMJ (temporomandibular joint disorder)? No If yes How many years: Do you have a painful cracking of the jaw? Do you grind or clenching your teeth? No Yes No Yes 18. Do you suffer from: Arthritis Thyroid gland Headache - migraine Hypertension Allergies Neck problems - cervical Sinusitis Anemia High cholesterol level Diabetes Constipation Do you have prosthesis? No Yes Dizziness- vertigo Clinical depression Anxiety Obsessive - compulsive behavior Bipolar/Manic-depressive behavior 19. Do you take any medication at the moment? No If yes, which one(s) and what are the directions for use (aspirin included). 20. Do you smoke: Tobacco How many years: How many per day: Marijuana How many years: How many per day: Other drugs, which ones: How many years: How many per day:
6 21. Do you drink any of these (please indicate the number of "small" cups or glasses per day): Coffee with caffeine Hot chocolate Tea with caffeine Alcohol, which one Soft drinks with caffeine Tonic water (ex. gin tonic) Energy dink 22. Do you use any of these on a daily basis? Sugar Salt MSG Foods with additives Spices 23. Do you exercise regularly? No If yes, how many days a week? 24. Presently, are you going through many stressful situations? No If yes, why? 25. In general, are you satisfied with your lifestyle? Very unsatisfied Satisfied Very satisfied If you are unsatisfied, it is primarily due to your Hypoacusis Hyperacusis Tinnitus 26. Please indicate your fears regarding your hypoacusis / hyperacusis / tinnitus: 27. I want help with my hypoacusis / hyperacusis / tinnitus because: 28. Other comments: Signature: Date: FOR INTERNAL USE ONLY TINNITUS EVALUATION SYSTEM (From A.Kodama, M.Kitahara, K.Komada, 1994): L( ) + A ( ) + I ( ) = L( ) + A ( ) + I ( ) = L( ) + A ( ) + I ( ) =
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Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
Who referred you to us?
CHICAGO CENTER FOR MYOFASCIAL PAIN RELIEF Please fill this form out before you arrive for your first appointment, it will save time when you are with us. Contact Information TODAY S DATE: NAME ADDRESS:
Sleep. Information booklet. RDaSH. Adult Mental Health Services
Sleep Information booklet RDaSH Adult Mental Health Services Sleep problems are often referred to as insomnia. They are very common, particularly in women, children and people over 65, so it is quite normal
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
REGISTRATION AND HEALTH HISTORY
REGISTRATION AND HEALTH HISTORY Name: Social Security #: Name we should call you: Date of Birth: Home Phone #: Cell #: E-mail Address: Address: Employed By: Position: Work Phone# Marital Status: Spouse
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
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Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
Physiotherapy Assessment (Condition > 4 weeks)
Greg de Jong: Physiotherapist & Nutritionist 35 Beach Street Merimbula NSW 2548 Ph: 02 64951097 Fax: 02 64951397 Physiotherapy Assessment (Condition > 4 weeks) By accurately and in detail completing this
Instructions. If you make a mistake, put an "X" over the checkmark. Then put a checkmark in the correct box and draw a circle around that box.
SLEEP HEART HEALTH STUDY SLEEP HABITS AND LIFESTYLE QUESTIONNAIRE Instructions Thank you for taking time to fill out the enclosed Sleep Habits Questionnaire. Please fill out the form completely. You may
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
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Sleep Questionnaire. If yes, what? If yes, how would you describe it? Please explain? If yes, what times are these?
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NEW PATIENT INFORMATION
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Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
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Corner on Wellness Chiropractic Center Therapeutic Massage
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Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
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