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Tinnitus and hyperacusis therapy specialist unit
Sound Sensitivity (Parent)
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.
Over the last 2 weeks, how often has
your child
been bothered by any of the following problems?
1. Having a problem tolerating sounds because they often seem “too loud” to them?
0-1 day
2-6 days
7-10 days
11-14 days
2. Pain in their 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 their 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. Feeling frightened when hearing certain loud sounds?
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
Submit
For Hearing Healthcare Professionals