To download a PDF of this form, please CLICK HERE! Personal Information: Name * Date of Birth * Phone # * Email * What location are you visiting? * AmherstWilliamsvilleOrchard ParkTonawanda Nature of the Tinnitus (How does the tinnitus sound?) * Usual site of the tinnitus? * Left=RightLeft worse than RightRight worse than LeftCentral Is the tinnitus constant or intermittent? * Does the tinnitus fluctuate in intensity? * What makes your tinnitus worse? * What makes your tinnitus better? * How did you hear about us?* TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther If other, please explain:* Tinnitus History: When did you first become aware of your tinnitus? * When did your tinnitus first become disturbing? * Under what circumstances did the tinnitus start? * What do you consider to have started the tinnitus? * Who have you consulted about your tinnitus? * What have previous professionals said your tinnitus is due to? * What treatments have you tried for your tinnitus? * NoneHearing AidMaskerTRTCounsellingMusic TherapyOther How successful did you find these treatments? * Have you ever been exposed to gunfire or explosion? * YesNo Details/Comments Have you ever attended loud events e.g. music concerts or clubs? * YesNo Details/Comments Have you ever had any noisy jobs? * YesNo Details/Comments Have you ever had any noisy hobbies or home activities? * YesNo Details/Comments Have you ever had any head injuries or concussion? * YesNo Details/Comments Have you ever had any operations involving your ear or head? * YesNo Details/Comments Have you ever taken any of the following medications? (Quinine, Quindidine, Streptomycin, Kantamycin, Dihydrostreptomycin, Neomycin) * YesNo Details/Comments Have you ever used solvents, thinners or alcohol based cleaners? * YesNo Details/Comments Do you have loose dentures, jaw pain or grinding and clicking sensations in the jaw? * YesNo Details/Comments Do you regularly take aspirin or dispirin? * YesNo Details/Comments Do you ave any feelings of ear pressure or blockage? * YesNo Details/Comments Do you find exposure to moderately loud sounds make your tinnitus worse? * What is your current occupation? * General Hearing Problems: Do you have any difficulties hearing when there is background noise? * YesNo Details/Comments Do you have difficulties understanding in one-to-one conversations? * YesNo Details/Comments Do you have difficulties hearing the TV? * YesNo Details/Comments Do you have difficulties hearing on the telephone? * YesNo Details/Comments Do you have any dizziness or balance problems? * YesNo Details/Comments Do you find external sounds unpleasant or uncomfortable? * YesNo Details/Comments Do you dislike certain external sounds? * YesNo Details/Comments Do you wear ear protection/ ear plugs? * YesNo Details/Comments What auditory problems do you experience? * Hearing LossTinnitusSensitivity to Loud Sounds Effect of the Tinnitus: Over the past week, what percentage of the time you were awake were you aware of your tinnitus (e.g. 100% aware all the time, 25% aware ¼ or the time)? * What percentage of the time was it disturbing? * Does your tinnitus prevent you from getting to sleep at night? Y/N * How many times per night did you awake in the last week? * How has tinnitus affected your work life? * How has tinnitus affected your home life? * How has tinnitus affected your social activities? * General Health: What is your general health like? * Are you taking any medications? (If yes, please specify) * Compensation: 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? * Medical Contact Details: Name and Address of GP: * Name and Address of ENT: * I give consent to release results to my GP/ENT: * YesNo Is there anything else you would like to add that might be relevant to understanding what caused your tinnitus? * Δ Please arrive 15 minutes prior to your scheduled appointment time.