Tinnitus and hyperacusis therapy specialist unit

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

Hyperacusis 2

Please answer each item to the best of your ability, as close to your experience as possible.

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. Compared to most people, common everyday sounds seem excessively loud to me:
Not at all	A little	Somewhat	Very much so

2. Sound can cause me pain and/or physical discomfort
Not at all	A little	Somewhat	Very much so

Hearing sounds can make me feel:
3. Stressed out	Not at all	A little	Somewhat	Very much so
4. Tense	Not at all	A little	Somewhat	Very much so
5. Angry	Not at all	A little	Somewhat	Very much so
6. Irritated	Not at all	A little	Somewhat	Very much so

My sensitivity to sounds can make it difficult:
7. To cope	Not at all	A little	Somewhat	Very much so
8. To concentrate	Not at all	A little	Somewhat	Very much so
9. To relax	Not at all	A little	Somewhat	Very much so
10. To sleep	Not at all	A little	Somewhat	Very much so
11. To maintain important work, academic and/or household responsibilities	Not at all	A little	Somewhat	Very much so
12. To have the social life I wish to have	Not at all	A little	Somewhat	Very much so
13. To take part in meaningful activities I used to enjoy	Not at all	A little	Somewhat	Very much so

My increased sound sensitivity can make me feel:
14. Hopeless	Not at all	A little	Somewhat	Very much so
15. Alone or Isolated	Not at all	A little	Somewhat	Very much so
16. Afraid	Not at all	A little	Somewhat	Very much so
17. Frustrated	Not at all	A little	Somewhat	Very much so
18. Tired or fatigued	Not at all	A little	Somewhat	Very much so

I find the challenges of being exposed to loud sounds:
19. Difficult to explain to my friends and family	Not at all	A little	Somewhat	Very much so
20. Difficult to explain to doctors and other caregivers	Not at all	A little	Somewhat	Very much so
21. Can make it difficult to be in loud places	Not at all	A little	Somewhat	Very much so
22. Can make it harder to use transportation (cars, buses, trains, bicycle, motorbike etc).	Not at all	A little	Somewhat	Very much so
23. Can make me afraid to leave my house for fear I may be exposed to loud sounds	Not at all	A little	Somewhat	Very much so
24. Has made it more of a problem to get around	Not at all	A little	Somewhat	Very much so
25. Can make it difficult to do the things I used to enjoy	Not at all	A little	Somewhat	Very much so

For Hearing Healthcare Professionals