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Misophonia Impact Questionnaire (Parent Version)
Please answer each item to the best of your ability as close to your child’s experience as possible.
Over the last 2 weeks, how often would you say the following has occurred
because of your child’s intolerance to
certain sounds related to eating, chewing gum, lip smacking, mouth noises, sniffling, breathing, clicking, and tapping?
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
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
2. Unable to ignore certain sounds
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
3. Experiencing difficulties in their relationships with family members or friends
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
4. Feeling angry
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
5. Finding it difficult to be around certain individuals because of the noises that they make
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
6. Feeling irritated
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
7. Avoiding certain situations because of the noises that they have to put up with
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
8. Experiencing low mood because of their intolerance to certain sounds
0 - 1 day
2 - 6 days
7 - 10 days
11 - 14 days
Submit
For Hearing Healthcare Professionals