Cincinnati Hearing And Tinnitus, Inc. (CHAT)
Marlo M. Bailey, AuD Board Certified in Audiology F-AAA, TPA
7763 Montgomery Rd. 2 nd Floor Cincinnati, OH 45236 www.cincyhearing.com
• Phone: 513-675-8595 • Fax: 513-891-6642 • Email: drbailey@cincyhearing.com
Tinnitus History Form
Tinnitus
Tinnitus refers to any kind of sound in your head… ringing hissing and so on. Think about your tinnitus ONLY in regard to
the following questions.
How does the tinnitus sound? ______________________________________________________________________
Please circle:
Is it Constant or Intermittent? Constant Intermittent
Which ear? Right Left Both Central
How long ago did you notice the tinnitus? Recently
1-3 years ago
3-10 years ago
More than 10 years ago
When did the tinnitus become disturbing? Recently
1-3 years ago
3-10 years ago
More than 10 years ago
Was it a sudden onset or a progressive onset? Sudden Progressive
Was it related to any other medical or environmental conditions?
Yes
No
Do you know what started the tinnitus?
Yes
No
If yes, please explain. ____________________________________________________________________________
Does your tinnitus pulse with your heartbeat?
Yes
No
Is your tinnitus triggered by head or neck movement?
Yes
No
Does the tinnitus fluctuate in intensity (loudness)
Yes
No
Does the tinnitus fluctuate in pitch?
Yes
No
What makes your tinnitus worse? ______________________________________________________________________
What makes your tinnitus better? ______________________________________________________________________
Have you consulted any other professional or tried any treatment for your tinnitus?
Yes
No
If yes, please explain. ____________________________________________________________________________
Have you ever been exposed to gunfire?
Yes
No
Have you ever been exposed to noise in a job/club/hobby?
Yes
No
If yes, please explain. ____________________________________________________________________________
Have you taken any of the following medications? (please circle)
Quinine
Quindidine
Streptomycin Kantamycin Dihydrostreptomycin Neomycin
Do you have loose dentures, jaw pain or grinding or clicking sensations in the jaw? Yes
No
Do you regularly take aspirin or dispirin?
Yes
No
Does exposure to moderately loud sounds make your tinnitus worse? Yes
No
If yes, please explain. ____________________________________________________________________________
Do you have feelings of ear fullness or blockage?
Yes
No
Do you have excessive ear wax?
Yes
No
Do you have any hearing difficulties? (TV, background noise etc.)
Yes
No
Have you ever had a head injury or concussion?
Yes
No
If yes, please explain. ___________________________________________________________________________
Do you use earplugs specifically for tinnitus?
Yes
No
Which is the most bothersome? Tinnitus
Hearing loss
Sensitivity to loud sounds
Over the past week, what percentage of the time were you aware of your tinnitus?
100% 75% 50%25% 0%
Over the past week, what percentage of the time were you bothered by your tinnitus? 100% 75% 50% 25% 0%
Does your tinnitus prevent you from going to sleep?
Yes
No
How many times has your tinnitus woken you up in the past week? ______
How has tinnitus affected your life?
Are you currently pursuing any form of compensation, sickness benefit, DVA, motor vehicle accident claim or any other
legal action in relation to your tinnitus?
Yes
No
Is there anything else you would like to add about your tinnitus?___________________________________________
____________________________________________________________________________________________