X hits on this document

142 views

0 shares

0 downloads

0 comments

47 / 51

TINNITUS SAMPLE CASE HISTORY QUESTIONNAIRE (TSCHQ)

NAME:

DATE:

DATE OF BIRTH:

1.

ge:

2.

Gender:

Male

Female

3.

Handedness

Right

Left

Both Sides

4.

Family history of tinnitus complaints

YES

if YES:

parents

siblings

children

NO

5.

Initial onset: When did you first experience your tinnitus?

____________________

6.

How did you perceive the beginning?

Gradual

Abrupt

7.

Was the initial onset of your tinnitus related to:

loud blast of sound

whiplash

head trauma

others

change in hearing

stress

8.

Does your tinnitus seem to PULSATE ?

YES with heart beat

YES, different from heart beat

NO

Document info
Document views142
Page views142
Page last viewedMon Dec 05 19:24:32 UTC 2016
Pages51
Paragraphs627
Words24436

Comments