The following questions are Optional - but they help the network remember what specific problems you are experiencing.

1. Condition(s) you have and how long you've had them:
   ( ) Hyperacusis (sound sensitive but no hearing loss)
   
   ( ) Recruitment (sound sensitive with hearing loss)
   
   ( ) Tinnitus (ringing in your ears or other head noises)
   
   ( ) Vertigo (dizziness/balance disorder)
   
   ( ) Meniere's Disease (multiple vestibular disorder)
   
   ( ) Temporomandibular Joint Syndrome (TMJ)
   
   ( ) Autistic, or parent of an autistic child/adult
   
   ( ) Others, please describe
   
   
2. If you have multiple conditions, which one is the worst?
   
   
   
3. Have your condition(s) improved or gotten worse?
   
   
   
4. Do you have these problems in one or both ears?
   
   
   
5. Do you experience pain or a feeling of fullness (pressure) in your ear(s)? Please describe:
   
   
   
6. On an average, how much time in each day do you use ear protection (foam plugs, ear muffs, etc.)?
   
   
   
7. As time goes by, do you find yourself spending more or less time wearing ear protection?
   
   
8. Do the high or low frequencies bother you the most?
   
   
9. Did your condition happen as the result of a noise injury or trauma to the head? Please explain in detail.
   
   
   
10. When was your last hearing test? Did it show a hearing loss?
    
    
    
11. Yes No
    Are you currently employed?
    If so, what do you do for a living:
    
    
12. Yes No
    Can you tolerate the sound of a human voice?
    
    
13. Yes No
    Are you currently taking any medication?
    If yes, what kind and dosage:
    
    
14. What are these drugs doing for you?
    
    
15. Yes No
    Are you taking any vitamin supplements?
    If yes, what kind and dosage?
    
    
16. Yes No
    Have you ever tried sound desensitization therapy (TRT - Tinnitus Retraining Therapy; listening to pink noise tapes)
    If yes has it helped Yes No
    
    
17. Where have you been to seek help?
    
    
    
18. Yes No
    Does your physician understand your problems?
    
    
19. Yes No
    Do you have problems sleeping at night?
    
    
20. How are you coping with these problems and how is your family coping with your condition?
    
    
    
21. Yes No
    Do you have allergies?
    
    
22. Yes No
    Does anyone else in your family have hearing problems?
    If yes describe:
    
    
    
23. Yes No
    Do you believe in God?
    
    
24. Married Live alone
    Are you married or living alone?
    
    
25. What has been the most difficult part of your hearing problems?
    
    
    
26. What agency, doctor or support group has been most helpful to you in your search for answers and help?
    
    
    
27. How did you find out about the Hyperacusis Network?
    
    
    
28. Yes No
    Are you interested in sharing information with others throughout the world who have hyperacusis?
    
    
29. Yes No
    Would you be able or interested in traveling to appear on a nationally televised talk show (like Oprah)?
    
    
30. Yes No
    Do you have a photo of yourself (not for publication, but for the network bulletin board)?
    

Please return this completed form to:

The Hyperacusis Network
Post Office Box 8007
Green Bay, Wisconsin 54308

No dues - DONATIONS are gratefully accepted