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Hyperacusis Impact Questionnaire (Adult Version)
Please answer each item to the best of your ability as close to your experience as possible.
Over the last 2 weeks, how often would you say the following has occurred because of certain environmental sounds which seemed too loud to you but people around you could tolerate them well?
Name of the patient:
Email of the patient:
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.
(Use "✓" to indicate your answer)
1. Feeling anxious when hearing loud noises
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
2. Avoiding certain places because it is too noisy
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
3. Lack of concentration in noisy places
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
4. Unable to relax in noisy places
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
5. Difficulty in carrying out certain day-to-day activities/tasks in noisy places
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
6. Lack of enjoyment from leisure activities in noisy places
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
7. Experiencing low mood because of your intolerance to sound
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
8. Getting tired quickly in noisy places
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
Submit
For Hearing Healthcare Professionals