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4c Tinnitus Management Questionnaire
Tinnitus is the sensation of sound in the ears or head without any external sound source. It may sounds like a buzzing, whistle, ringing, humming, pulsing or other types of sound.
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 with tinnitus?
0
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9
10
2. How confident are you that you are able to rest and relax even with tinnitus?
0
1
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9
10
3. How confident are you that you can enjoy your life fully even with tinnitus?
0
1
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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., using background noise or avoiding certain situations)?
0
1
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9
10
Submit
For Hearing Healthcare Professionals