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“Items list” for tinnitus case history questionnaires. Items are ordered according to their level of significance: Category “A” (= essential) in bold type.

Background

  • 1.

    Age.

  • 2.

    Gender.

  • 3.

    Handedness.

  • 4.

    Family history of tinnitus (parent, sibling, children).

Tinnitus history

  • 5.

    Initial onset. Time?

  • 6.

    Initial onset. Mode? Gradual or abrupt?

  • 7.

    Initial onset. Associated events? Hearing change, Acoustic trauma, Otitis media,

Head trauma, Whiplash, Dental Treatment, Stress, Other.

  • 8.

    Pattern. Steady? Pulsatile? Other?

  • 9.

    Site. Right ear? Left ear? Both ears? (symmetrical?) Inside head?

  • 10.

    Intermittent or constant?

  • 11.

    fluctuant or non-fluctuant?

  • 12.

    Loudness. Scale 1-100. At worst & at best?

  • 13.

    Quality. Own words / Give a list of choices.

  • 14.

    Pure tone or Noise? Uncertain / polyphonic?

  • 15.

    Pitch. Very high? High? Medium? Low?

  • 16.

    Percentage of awake time aware of tinnitus?

  • 17.

    Percentage of awake time annoyed by tinnitus?

  • 18.

    Previous tinnitus treatments (no, some, many)?

Modifying influences

  • 19.

    Natural masking? Music, everyday sounds, other sounds?

  • 20.

    Aggravated by loud noise?

  • 21.

    Altered by head and neck movement or touching of head or upper limbs

(specification of the respective movements)?

  • 22.

    Daytime nap. Worse? Better? No effect?

  • 23.

    Effect of nocturnal sleep on daytime tinnitus?

  • 24.

    Effect of stress?

  • 25.

    Effect of medications? Which?

Related conditions

  • 26.

    Hearing impairment?

  • 27.

    Hearing aids (No, left ear, right ear, both ears; effect on tinnitus)?

  • 28.

    Noise annoyance or intolerance?

  • 29.

    Noise induced pain?

  • 30.

    Headaches?

  • 31.

    Vertigo/dizziness?

  • 32.

    Temporomandibular disorder?

  • 33.

    Neck pain?

  • 34.

    Other pain syndromes?

  • 35.

    Under treatment for psychiatric problems?

As an example of how the above items can be expressed for patients to complete see the

TINNITUS SAMPLE CASE HISTORY QUESTIONNAIRE (TSCHQ)

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