The Ear Foundation Santa Barbara


PATIENT HISTORY QUESTIONNAIRE

Patient Name: _________________________________ Date: _______________

Address:_________________________________________________________________

Date of Birth: ________________ Sex: _______ Phone: ( ) _________________


CANDIDACY CHECKLIST

Yes    No

_____ _____ allergy to propylene glycol
_____ _____ 18 years old and can understand and sign consent
_____ _____ taking vasoconstrictors or decongestants
_____ _____ pregnant
_____ _____ subject to weight fluctuations
_____ _____ middle ear ventilation tube(s)
_____ _____ upper respiratory infections
_____ _____ previous Eustachian tube surgery or Teflon injection
_____ _____ previous participation in one of our studies
_____ _____ current medication (list): _____________________________

_____________________________________________________________

A. Do you ever experience in either ear:

1. The sensation of hearing your breath sounds (amphoria)?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

2. The sensation of hearing our own voice being annoying or abnormally loud (autophony)?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

3. The sensation of your breathing or voice being annoying or abnormally loud (autophony)?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

4. The sensation of fullness or feel stopped up especially when you yawn or swallow?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

5. A crackling sound when gently blowing your nose, or saying "m" or "n" sounds?
_____ No
_____ Yes - How often: ___Seldom ___Occasionally ___Often ___Almost Always

B. To what extent do any of the above 3 symptoms bother or annoy you?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

C. To what extent do any of the above 3 symptoms disable you?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

D. To what extent have these symptoms impaired your concentration or memory of details?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

E. To what extent do these symptoms make you anxious, nervous or tense?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

F. To what extent have these symptoms decreased your enjoyment of life?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

G. To what extent have these symptoms reduced your social activities?

1. Not at all
2. Not at all to slightly
3. Slightly
4. Moderately
5. Very
6. Very to extremely
7. Extremely

H. Do the symptoms which you described in (A) occur in? (Circle one)

Left      Right      Both ears

I. When did you first start having these symptoms?

_______________________________________________________________________________

_______________________________________________________________________________

J. On the average, how often do the above symptoms occur? (Circle one)

1. Daily
2. 5-6 times a week
3. 3-4 times a week
4. 1-2 times a week
5. Less than once a week

K. How soon after arising in the morning do the symptoms typically begin?

1. Immediately
2. Within 1/2 hour
3. Within 1 hour
4. Within 2 hours
5. More than 2 hours
6. Extremely variable

L. What percentage of the time (0%, 10%, 90%, or whatever) are the ear symptoms present in the

Right ear _______________ Left ear _______________


M. Do any of the above 3 symptoms which you have disappear when (circle one)

1. You lie down?                                                                   No Yes
2. You have a cold?                                                               No Yes
3. When you put your head down, e.g., between your knees?      No Yes
4. When you sniff?                                                                No Yes
5. When you swallow?                                                           No Yes
6. When you have an allergy? N/A (no allergies)                        No Yes

N. Do any of your ear symptoms become worse when you

1. Exercise                                                                           No Yes
2. Are tired or fatigued?                                                         No Yes
3. Are stressed (nervous, anxious, tense etc.)?                         No Yes

O. Do the ear symptoms change with jaw position?

No       Yes

If yes, explain: _____________________________________________________________

__________________________________________________________________________

P. Do you have any other general illness?      No      Yes

If YES, what? _______________________________________________________________

How long? _________________________________________________________________

Q. Do you take any birth control pills or other hormones?      No      Yes

If YES, what do you take? _____________________________________________________

R. Have you lost weight?      No      Yes

If YES, how much? __________________ When? __________________

S. Have you ever had radiation therapy?      No      Yes

If YES, where? _____________________ When? __________________

T. How many doctors have you consulted about this condition before coming here?

Number __________

U. Which other ear symptoms do you have? Hearing loss, dizziness, ringing – which ear?

__________________________________________________________________________

__________________________________________________________________________


Please return this form to your project physician, Dr. _______________.

Please call (        ) ______________, if you have any questions.