Initial Tinnitus Assessment Form

Delray Beach, FL 33484
(561) 332-4977

Boynton Beach, FL 33437
(561) 292-0109

Jupiter, FL 33458
(561) 888-7260

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Home
About Us
Services
Hearing Aids
Tinnitus
- About Tinnitus
- Treatment Options
Patient Resources
Referring Physicians
FAQ
Blog
Shop
Review Us
Our Locations
Events
Contact Us

PATIENT INFORMATION

Patient Name

Date of Birth

Phone Number

Date of Consultation

Practitioner

Tinnitus Aspects

How long have you had tinnitus?

< 3 months3 to 6 months6 months to 1 year1 to 2 years2 to 5 years5 to 10 years10 to 20 years> 20 yearsNot sure

Can you recall where you were or what you were doing when you first became aware?

What do you consider to be the cause of your tinnitus?

Please describe the onset of your tinnitus.

GradualAbruptNot sure

Please describe the sound of your tinnitus.

HissingWhistlingPure ToneRingingHummingDifficult to describeBuzzingCombination of soundsOther

Please specify:

Please describe the location of your tinnitus.

Left ear onlyRight ear onlyBoth earsInside my headCan't describeLeft ear worseRight ear worseOther

Please specify:

Please describe the frequency of your tinnitus.

ConstantFluctuatingIntermittent

What tinnitus treatment have you tried?

NoneHearing devicesNoise protectionTMJ treatmentTinnitus appsSound therapy (maskers / music / nature sounds)Psychotherapy (CBT / TRT Counseling / mindfulness)Music TherapyMedication (antidepressant / sleeping pills / antianxiety)Alternative therapies (reflexology / acupuncture)Neuromodulation (transcranial / bimodal)

Other:

Have you started any of the above treatments in the last 3 months?

YesNo

What type of health care professional provides this treatment?

Have you experienced anxiety / stress / depression as a result of tinnitus?

YesNo

Prior to today, have you seen a healthcare professional about your tinnitus?

YesNo

Have you been diagnosed with any medical conditions related or unrelated to your tinnitus?

YesNo

Please describe:

Do you regularly take aspirin?

YesNo

Have you taken any new medication in the last 3 months?

YesNo

Please mark any you have taken.

QuinineQuinadineStreptomycinKatamycinDihydrostreptomycinNeomycin

Have you had an MRI regarding your tinnitus?

YesNo

Was the outcome normal?

YesNo

SLEEP

How many hours of sleep do you get each night?

How soon do you fall asleep?

Do you feel refreshed or well rested when you wake up?

YesNo

What medications, herbs, teas, etc. do you take to help you sleep?

PSYCHOLOGICAL

Have you ever experienced feelings of anxiety / stress / depression / or emotional struggles in general (prior to developing tinnitus)?

YesNo

Have you ever experienced feelings of anxiety / stress / depression as result of your tinnitus?

YesNo

Have you been clinically diagnosed with Anxiety?

YesNo

Have you been clinically diagnosed with Depression?

YesNo

Have you been clinically diagnosed with OCD?

YesNo

Have you been clinically diagnosed with ADHD?

YesNo

Do you feel you have hearing loss?

YesNoNot Sure

When was your last hearing exam?

What were the recommendations?

Do you currently wear hearing aids?

YesNo

Do you have trouble tolerating certain sounds?

YesNo

Have you been diagnosed with hyperacusis?

YesNo

HEARING RISK ASSESSMENT

Have you ever...

Been exposed to gunfire or explosion?

YesNo

Attend loud events? (concerts)

YesNo

Please describe:

Had noisy jobs?

YesNo

Please describe:

Have noisy hobbies or activities?

YesNo

Please describe:

Had any surgeries involving your ear(s) or head?

YesNo

Please describe:

Have you used or worked with solvents, thinner or alcohol-based cleaning agents?

YesNo

Please describe:

GENERAL

Do you...

Have loose dentures, jaw pain, grinding, clinching sensation in the jaw?

YesNo

Do you currently work?

YesNo

What level of stress do you have?

LowModerateSevere

LIFESTYLE

How much caffeine do you consume daily?

CoffeeChocolateEnergy DrinksSodaTea (black/green)

Other:

Do you drink alcohol?

YesNo

Number of drinks/week:

Do you use tobacco?

YesNo

Amount/day:

How long have you used tobacco?

If you have quit, when?

Do you use recreational drugs?

YesNo

Please describe:

Does your medical history include:

DiabetesRadiation therapyCompromised immune systemTMJChemotherapyCognitive ability

EXERCISE

Do you currently exercise?

SedentaryLight ActivityModerateActiveVery Active

COMPENSATION

Are you currently pursuing any form of compensation, sickness benefit, DVA, motor vehicle accident claim or any other legal action relating to your tinnitus?

YesNo

Please describe:

LENIRE CONTRAINDICATIONS

Pacemaker, defibrillator or any other active implantable device (unless directed by a doctor)Condition that may result in loss of consciousnessSores of oral cavity (unless directed by a doctor)Pregnant (unless directed by a doctor)Condition that causes impaired sensitivity of the tongueInflammation of the oral cavity (unless directed by a doctor)EpilepsyLesions of the oral cavity (unless directed by a doctor)Any intermittent or chronic neuralgia in the head/neck area

CLINICAL OUTCOMES

What would be the most successful treatment outcome for you?

Tinnitus less bothersomeImprovement in sleepImprovement in hearingImprovement in concentrationImprovement in mood (anxiety/stress/depression/emotional)

What would be the second most successful treatment outcome for you?

Tinnitus less bothersomeImprovement in sleepImprovement in hearingImprovement in concentrationImprovement in mood (anxiety/stress/depression/emotional)

What would be the third most successful treatment outcome for you?

Tinnitus less bothersomeImprovement in sleepImprovement in hearingImprovement in concentrationImprovement in mood (anxiety/stress/depression/emotional)

MEDICAL CONTACT DETAILS

Name and Address of Primary Doctor:

Name and Address of ENT:

I give consent to release my results/treatment to my Primary Doctor / ENT.

PRINT NAME

SIGNATURE

DATE

Welcome to Hearing Partners of South Florida! We are an independently owned, full service audiology practice focused on providing the highest quality of hearing care to each of our patients.

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Delray Beach Office

6110 W Atlantic Ave, Suite A, Delray Beach, FL 33484
(561) 332-4977
(561) 638-6531

Opening Hours:

Monday to Friday: 9am – 5pm

Boynton Beach Office

7593 Boynton Beach Blvd, Suite 100, Boynton Beach, FL 33437
(561) 292-0109
(561) 736-8878

Opening Hours:

Monday to Friday: 9am – 5pm

Jupiter Office

210 Jupiter Lakes Blvd. Building 3000, Suite 205-206, Jupiter, FL 33458
(561) 888-7260
(561) 972-4386

Opening Hours:

Monday to Friday: 9am – 5pm