Tinnitus and hyperacusis therapy specialist unit

Social Anxiety

Please indicate how much the following problems have bothered you during the past week. Mark only one box for each problem, and be sure to answer all items.

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.

Questionnaire	Not at all (0)	A little bit (1)	Somewhat (2)	Very much (3)	Extremely (4)
1. Fear of embarrassment causes me to avoid doing things or speaking to people
2. I avoid activities in which I am the centre of attention
3. Being embarrassed or looking stupid is among my worst fears

For Hearing Healthcare Professionals