Name: Hashir International
Address: 54 Quarry Street, Guildford, GU1 3UA, GB
Telephone: 01483 255605
Price range: £

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.</small ></label >

1. Having a problem tolerating sounds because they often seem “too loud” to you?	0-1 day	2-6 days	7-10 days	11-14 days
2. Pain in your ears when hearing certain loud sounds? Examples: loud music, sirens, motorcycles, building work, lawn mower, train stations.	0-1 day	2-6 days	7-10 days	11-14 days
3. Discomfort (physical sensations other than ear pain) in your ears when hearing certain loud sounds?	0-1 day	2-6 days	7-10 days	11-14 days
4. Feeling angry or anxious when hearing certain sounds related to eating noises, lip smacking, sniffling, breathing, clicking sounds, tapping?	0-1 day	2-6 days	7-10 days	11-14 days
5. Fear that certain sounds may make your hearing and/or tinnitus worse?	0-1 day	2-6 days	7-10 days	11-14 days
6. Getting disturbed because of general environmental noise (e.g., noise in your neighbourhood, nearby airports and industrial facilities, distant traffic sound, noisy pipes or cracking noises in the house, air conditioning, etc)?	0-1 day	2-6 days	7-10 days	11-14 days

Tinnitus and hyperacusis therapy specialist unit

Sound Sensitivity

Over the last 2 weeks, how often have you been bothered by any of the following problems?