Daytime phone: Home phone:

• Whendidyoufirstexperiencetinnitus?

• Howlonghaveyouhadtinnitusinitspresentform?yearsmonths

• Brieflydescribewhatyouweredoingwhenthetinnitusfirstbecameapparenttoyou:

• Wereyouexperiencinganykindofemotionaltraumaatthetimewhenyoufirstnoticedyourtinnitus?

•Whatdoyouthinkisthecauseofyourtinnitus?

• Whereisyourtinnitusprimarilylocated?

Leftear Rightear Bothearsequally Head

Other(pleaseexplain):

• Usingthescalebelow,indicatetheLOUDNESSof:

A)Yourtinnitusrightnow B)Youraveragetinnitus

C)Yourtinnitusatitsworst D)Yourtinnitusatitsleast

0 1 2 3 4 5 6 7 8 9 10None Mild Moderate SevereExcruciating

Name:Age:Date://

Referredby:

TinniTus INTAKE FORM

1/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

• Usingthescalebelow,indicatethePITCHofyourtinnitus: (Itmighthelptoimaginethescaleasifitwereapianokeyboard.)

0 1 2 3 4 5 6 7 8 9 10Lowpitch MidpitchHighpitch

• Theloudnessofyourtinnitusis(checkone):

fairlyconstantfromdaytoday

fluctuateswidely,beingveryloudsomedaysandverymildotherdays

usuallyconstant,butoccasionallydecreasesmarkedly

usuallyconstant,butoccasionallyincreasesmarkedly

• Doesyourtinnitusappearworse:

whentired whentenseornervous

atbedtime afteruseofalcohol

uponawakening whenrelaxed

• Checkallitemsbelowwhichdescribethesoundofyourtinnitus:

Hissing Ringing Cricket-like Whistle

Steamwhistle Pounding Pulsating Bells

Clanging Buzzing Sizzling Ticking

Oceanroar Hightensionwire Other:

• Towhatextentareyoubotheredorannoyedbyyourtinnitus?

0 1 2 3 4 5 6 7 8 9 10Notbothered Mild Moderate SevereExtreme

2/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

• Whenareyouawareofyourtinnitus?

• Whatpercentageofthetimeareyoubotheredbyyourtinnitus?

• Isthereanytimeduringthedaywhenyourtinnitusismosttroublesometoyou?

Atwork Inmorning

Inevening Whentryingtoconcentrate

Atsocialactivities Aroundnoise

Other:

• Doyouconsideryourselftobeatenseperson?

• Doyoufeelthatemotionalorphysicalstressworsensthetinnitus?

• Pleasetellushowyourtinnitusinterfereswithyouractivities:

Concentration

Work/Chores

Family

Religiousactivities

Social/Recreation

Exercise

Sleep

• Doesthetinnituspreventyoufromfallingasleep?

• Doesthetinnitusawakenyoufromsleep?

• Areyouabletofallbackasleep,onceawakened?

Other:

3/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

• Doyouhaveahearingloss?YesNo

• Whichismoreofaproblemforyou,thehearingdifficultyoryourtinnitus?

Hearingdifficulty Tinnitus Notsure

• Haveyoubeenexposedtoloudnoise?YesNo

Ifso,when?MilitaryserviceWorkRecreation

Other:

• Doyouwearearprotectioninthepresenceofloudsounds?

YesNo

• Haveyoueverwornahearingaid?YesNo

Ifyes,doyoucurrentlywearit(them)?YesNo

• Ifyouareahearingaiduser,howdoestheaidaffectyourtinnitus?

MakestinnitussofterMakestinnituslouderNoeffect

• Areyouadverselyaffectedbyloudsounds?YesNo

Pleaseexplain:

• Howwouldyourlifebedifferentifyoudidn’thavetinnitus?

• Haveyoudiscussedyourtinnituswithfriendsorfamilymembers?YesNo

Whatwastheirreaction?

• Arethereothermembersofyourfamilyorfriendswhosufferfromtinnitus?YesNo

• Doyoulivealone?YesNo

4/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

TREATMENT HISTORY• Pleaselistallevaluationsand/ortreatments(includingpsychiatricorpsychologic)youhavehadforyour tinnitus.Pleaseincludethenamesofthespecialistswhohaveperformedevaluationsortreatments,and theapproximatedatesonwhichtheywereperformed,usingthereverseside,ifnecessary.

Provider Whatwasdone? Date Result

1.

2.

3.

4.

5.

• Pleaselistanysurgeriesyouhavehad(potentiallyrelatedtoyourcurrentsymptomoftinnitus):

• Pleaselistthemedicationsyouarecurrentlytakingfortinnitus:

Medication Dose Howoften? Doesithelp? Doctor

YesNo

YesNo

YesNo

YesNo

• Whatothermedicationshaveyoutriedinthepastfortinnitusrelief?

Medication Dose Howoften? Doesithelp? Stopped(Why?)

YesNo

YesNo

YesNo

YesNo

5/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

• Pleaselistallothermedicationsyoucurrentlytake:

Medication Dose Howoften? Purpose? Doctor

• Usingthenumbercodesbelow,pleaseindicatetheresultsofthosetreatmentsyouhavetriedforyour tinnitus.Ifyouhavenottriedagiventreatment,pleaseplacean“NA”intheblankforthattreatment.

1=Majorrelief 2=Somerelief 3=Norelief 4=Somereliefwithbadsideeffects 5=Tinnitusworse NA=Notapplicable,treatmentnottried

Surgery Acupuncture

Drugtherapy Massage

Hearingaids Homeopathy

Maskingtherapy Biofeedback

Physicaltherapy Chiropractic

Antidepressants Relaxationtrainingorhypnosis

Exerciseprogram Psychotherapyorothercounseling

Dental DietaryManagementornutritioncounseling

Other:

• Areyouemployed? No.ofhoursperweek

• Whatisyouroccupation?

• Areyousatisfied?

• Ifnotemployed,isyourunemploymentduetotinnitus?

6/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.

• Doyouhaveanyear,noseorthroatdiseases?

• Doyouhaveanyotherdiseasesthataffectyouinyourdailylife?

• Anyotherissuesyouwouldlikeustoknowabout?

7/7Thisintakeformisreproducedwiththekindpermission ofDr.RobertSweetow,ProfessorattheUniversityofCalifornia,SanFrancisco.