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4C Misophonia Management Questionnaire
Misophonia is strong emotional reaction to certain trigger sounds. The trigger sounds are noises related to chewing food, swallowing, tapping, breathing, lip smacking, nose sniffing, muffled speech or music, tapping, and other man made noises.
Name of the patient:
Your Email Address:
Please type the email address that this form needs to be sent to.
This is often the email address of your clinician who asked you to complete this form.
For each question please select one number based on how you are feeling now.
1. How confident are you that you are able to carry out your day-to-day tasks even when you hear the trigger noises?
0
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10
2. How confident are you that you are able to socialise and relax even when you hear the trigger noises?
0
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9
10
3. How confident are you that you can enjoy your life fully despite your misophonia?
0
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9
10
4. How confident are you that you can do all the above without using any avoidance behaviour (e.g., use of background noise, ear protection, telling people to stop the noise, mimicry, or avoiding certain situations or individuals)?
0
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9
10
Submit
For Hearing Healthcare Professionals