THE HEARING SOLUTION - New Patient Tinnitus Form

Rows	Yes	No
Do you have a better hearing ear?
Have you experienced a sudden/progressive hearing loss in the last 90 days?
Have you had any ear surgeries?
Do you suffer from ear pain?
Do you have pressure or fullness in your ears?
Have you had chronic ear infections?
Do you have drainage from your ears?
Do you have a history of head trauma?
Do you have a family history of hearing loss?
Do you notice ringing/buzzing/tinnitus in your ears?
Do you have a history of excessive noise exposure?

Have you ever:

Rows	Yes	No
Had any noisy jobs?
Had any noisy hobbies or home activities?
Used solvents, thinners or alcohol based cleaners?

Do you:

Rows	Yes	No
Have loose dentures, jaw pain or grinding/clicking in your jaw?
Regularly take aspirin or other pain killers?
Have any difficulties hearing when there is background noise?
Have any difficulties hearing the TV?
Have any difficulties hearing on the telephone?
Wear ear protection/earplugs?
Find certain sounds unpleasant, uncomfortable or too loud?

Effects of your tinnitus:
Over the past week, what percentage of the time were you aware of your tinnitus?
What percentage of the time was it disturbing?
Describe the sound of your tinnitus (hissing, ringing, buzzing, etc.)
In which situations do you notice your tinnitus the most?
In which ear do you hear your tinnitus?
Is it worse in one ear?
Is your tinnitus:

Rows	Yes	No
Does your tinnitus fluctuate in loudness?
Do you find exposure to moderately loud sounds makes your tinnitus worse?
Does your tinnitus affect your sleep?
Have you tried any medications in the past for your tinnitus?
Are you pending any legal action?

What makes your tinnitus worse?
What makes your tinnitus better?
How has tinnitus affected your work life?
How has tinnitus affected your home life?
How has tinnitus affected your social life?
Tinnitus History
When did you first become aware of your tinnitus and what do you consider to have first started your tinnitus?
When did your tinnitus first become disturbing? Any specific situation?
Who have you consulted about your tinnitus?
What have you been told about your tinnitus?
What treatments have you already tried for you tinnitus?

Other
How successful were these treatments?
Please rank the auditory problems you experience:

Hearing Difficulties:

	1	2	3	4	5	6	7	8	9	10

1 is Perfect Hearing, 10 is Severe Hearing Loss

Tinnitus:

	1	2	3	4	5	6	7	8	9	10

1 is Not Very Troublesome, 10 is Very Troublesome

Sensitivity to Loud Sounds:

	1	2	3	4	5	6	7	8	9	10

1 is Not Very Troublesome, 10 is Very Troublesome

New Patient History Form