Misophonia Questionnaire



Download 84.48 Kb.
Date conversion04.06.2018
Size84.48 Kb.

Misophonia Questionnaire

This questionnaire was developed to further the research of Misophonia/Soft-sound Sensitivity Syndrome/Selective Sound Sensitivity Syndrome/4S, hereafter referred to as Misophonia. It is not to be used to diagnose or treat Misophonia.

Fill out the questionnaire to the best of your ability. Any and all information is completely optional to provide. All information is strictly anonymous. You may choose to complete as much or as little of this questionnaire as you wish. However, please remember that the more information, the more comprehensive the results – no data is bad data.

Today’s Date: ____/____/____

City, State/Province: __________________________________ Country: ______________________________________



Section A: Identifying Information I choose not to disclose this information.

Date of Birth: ____/____/____ Age:

Sex: M F Prefer not to disclose.

Ethnicity Race:



Section B: Family I choose not to disclose this information.

Mother’s age:



Ethnicity: Race

Father’s age:

Ethnicity: Race:


Section C: Family History I choose not to disclose this information.

Indicate any health complications of your immediate and extended family. Immediate family is considered to be parents or siblings. Extended family is considered to be everyone else who is blood related.

Complication

Diagnosed?

Mother/Father

Sibling

Blood Relative

Speech/Language Disorder

Yes No










Mental Illness

Yes No










Hearing Problems/Deafness

Yes No










Thyroid Disorder

Yes No










Neurological Disorder

Yes No










Obesity

Yes No










Has any family member been diagnosed with Autism or an Autism Spectrum Disorder? Yes No

__________________________________________________________________________________________________

Has any family member been diagnosed with Misophonia? If so, whom? Yes No

__________________________________________________________________________________________________

Does any family member exhibited Misophonic symptoms? If so, whom? Yes No

__________________________________________________________________________________________________

Comments: __________________________________________________________________________________________________

__________________________________________________________________________________________________



Section D: Pregnancy, Labor & Delivery I choose not to disclose this information.

The following questions are important in providing insight into your birthing conditions. Please answer to the best of your ability and provide a brief explanation if answering ‘yes.’

Any maternal medications taken during pregnancy? Yes No

__________________________________________________________________________________________________

Maternal drug or alcohol abuse during pregnancy? Yes No

__________________________________________________________________________________________________

Maternal smoking during pregnancy? Yes No

__________________________________________________________________________________________________

Any significant maternal injuries or blunt trauma during pregnancy? Yes No

__________________________________________________________________________________________________

Were there any infections during pregnancy or birth? Yes No

__________________________________________________________________________________________________

Maternal medical illnesses or disease during pregnancy or birth? Yes No

__________________________________________________________________________________________________

Any other pregnancy complications? Yes No

__________________________________________________________________________________________________

Comments: __________________________________________________________________________________________________

__________________________________________________________________________________________________


Section E: Personal Health History I choose not to disclose this information.

For the following, please include dates, duration and frequency.

Have you ever been hospitalized? Please include reason. Yes No

__________________________________________________________________________________________________

Have you experienced an illness or disease? Yes No

__________________________________________________________________________________________________

Have you suffered any significant head injury or head trauma? Yes No

__________________________________________________________________________________________________

Have you experienced traumatic sound exposure or acoustic shock? Yes No

__________________________________________________________________________________________________

Have you ever had hearing or vision tests done? If so, what were the results? Yes No

__________________________________________________________________________________________________

Have you ever had an MRI? Yes No

__________________________________________________________________________________________________

Current or past medications taken? Please include dosage and length taken. Yes No

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Do you take any nutritional supplements? Yes No __________________________________________________________________________________________________

Do you have any allergies? Yes No

__________________________________________________________________________________________________

What immunizations have you had to date?

__________________________________________________________________________________________________

On a weekly basis, how often do you exercise?

__________________________________________________________________________________________________


For the following, please indicate diagnosis and date of diagnosis.

Depression Yes No ____/____/____

Anxiety Yes No ____/____/____

Obsessive Compulsive Disorder Yes No ____/____/____

Autism /Autism Spectrum Disorder Yes No ____/____/____

Sensory Integration Disorder Yes No ____/____/____

Mania Yes No ____/____/____

Bi-polar Yes No ____/____/____

Schizophrenia Yes No ____/____/____


For the following, please include dates, duration and frequency.

Ear Infections Yes No ____/____/____

Seizures Yes No ____/____/____

Loss of consciousness Yes No ____/____/____

Sleep problems Yes No ____/____/____

Serious injuries to body Yes No ____/____/____

Specific head injuries Yes No ____/____/____

Suffered from abuse Yes No ____/____/____

Tinnitus Yes No ____/____/____

For the following questions, indicate if you exhibit any of these conditions. If so, please give a brief explanation.



Oversensitivity to smells

Yes No




Crashing into others or objects

Yes No




Difficulty with handwriting

Yes No




Increased pencil pressure

Yes No




Make repetitive vocal sounds

Yes No




Blink excessively

Yes No




Sensitivity to clothing

Yes No




Sensitive to getting dirty

Yes No




Frequently grind teeth

Yes No




Able to relax

Yes No




Excessive fears or concerns

Yes No




Sleep excessively

Yes No




Resist comforting

Yes No




Impulsivity or carelessness

Yes No




Unable to express feelings

Yes No




Cope well with frustration

Yes No




Oversensitive vision

Yes No




Comments: __________________________________________________________________________________________________

__________________________________________________________________________________________________



Section F: Concern Identification I choose not to disclose this information.

For this section, please include length, dates and a brief description.

How long have you been living with Misophonia?

__________________________________________________________________________________________________

At what age did the triggers first emerge?

__________________________________________________________________________________________________

What were you doing when you experienced your first trigger? Where were you?



__________________________________________________________________________________________________

__________________________________________________________________________________________________

What things have you tried so far to alleviate or cope with your Misophonic symptoms?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Do you have your own ideas of what may have caused your Misophonia?

__________________________________________________________________________________________________

Is your Misophonia particularly worse with certain family or friends? If so, what is their relationship to you?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Does it get progressively worse over time?

__________________________________________________________________________________________________

Have any of your triggers subsided, decreased or gone away? If so, do you have any idea why?

__________________________________________________________________________________________________

What emotions do you feel when triggered?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Do you feel you must to say or do something to overcome the emotional response when triggered (i.e. mimic, echo)?

__________________________________________________________________________________________________

Are there any precursors such as tiredness, hunger or stress that worsen symptoms?

__________________________________________________________________________________________________

Do you experience an emotional response if you see, but cannot hear a trigger (visual trigger)?

__________________________________________________________________________________________________

Have you consulted a health care professional such as a psychologist, MD/Psychiatrist, Counselor, Nurse Practitioner, etc. for Misophonia? What was the result?



__________________________________________________________________________________________________

__________________________________________________________________________________________________

Have you undergone sound therapy (Pink, white or narrow-band noise, fractal music, etc.)?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

What other clinical therapies have you tried (i.e. neurofeedback, cognitive behavioral, hypnosis)?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Were any of these therapies successful in decreasing or alleviating your Misophonic symptoms?

__________________________________________________________________________________________________

With ‘1’ being low and ‘10’ being high, please indicate level of severity:

Discomfort Misophonia creates in your daily living 0 1 2 3 4 5 6 7 8 9 10

Guilt associated with reaction to triggers 0 1 2 3 4 5 6 7 8 9 10

Rage, panic, fear or terror in triggered situations 0 1 2 3 4 5 6 7 8 9 10

Irritation with repetitive behavior of others 0 1 2 3 4 5 6 7 8 9 10

Please list your most aggravating triggers:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

END

Thank you for your time and effort!



Completed questionnaires can be sent electronically to: misophoniaquestionnaire@yahoo.com

By mail to:

P.O. Box 191644

Sacramento, CA, USA 95819

Developed by Eric Vernon-Cole, School Psychology Graduate Student - California State University Sacramento.





The database is protected by copyright ©dentisty.org 2016
send message

    Main page