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Tinnitus and hyperacusis therapy specialist unit
Tinnitus Assessment
Please answer these questions based on your tinnitus within the last month.
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.
Because of your Tinnitus is it difficult for you to concentrate?
Yes
No
Sometimes
2.
Does the loudness of your Tinnitus make it difficult for you to hear people?
Yes
No
Sometimes
3.
Does your Tinnitus make you angry?
Yes
No
Sometimes
4.
Does your Tinnitus make you confused?
Yes
No
Sometimes
5.
Because of your Tinnitus are you desperate?
Yes
No
Sometimes
6.
Do you complain a great deal about your Tinnitus?
Yes
No
Sometimes
7.
Because of your tinnitus do you have trouble falling asleep at night?
Yes
No
Sometimes
8.
Do you feel as though you cannot escape from your Tinnitus?
Yes
No
Sometimes
9.
Does your Tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the cinema)?
Yes
No
Sometimes
10.
Because of your Tinnitus do you feel frustrated?
Yes
No
Sometimes
11.
Because of your Tinnitus do you feel that you have a terrible disease?
Yes
No
Sometimes
12.
Does your Tinnitus make it difficult to enjoy life?
Yes
No
Sometimes
13.
Does your Tinnitus interfere with your job or household responsibilities?
Yes
No
Sometimes
14.
Because of your Tinnitus do you find that you are often irritable?
Yes
No
Sometimes
15.
Because of your Tinnitus is it difficult for you to read?
Yes
No
Sometimes
16.
Does your Tinnitus make you upset?
Yes
No
Sometimes
17.
Do you feel that your Tinnitus has placed stress on your relationships with members of your family and friends?
Yes
No
Sometimes
18.
Do you find it difficult to focus your attention away from your Tinnitus and on to other things?
Yes
No
Sometimes
19.
Do you feel that you have no control over your Tinnitus?
Yes
No
Sometimes
20.
Because of your Tinnitus do you often feel tired?
Yes
No
Sometimes
21.
Because of your Tinnitus do you feel depressed?
Yes
No
Sometimes
22.
Does your Tinnitus make you feel anxious?
Yes
No
Sometimes
23.
Do you feel you can no longer cope with your Tinnitus?
Yes
No
Sometimes
24.
Does your Tinnitus get worse when you are under stress?
Yes
No
Sometimes
25.
Does your Tinnitus make you feel insecure?
Yes
No
Sometimes
Now please rank your tinnitus, on a scale of 0 to 10, with regard to severity, annoyance, and effect on your life. Please do not include hearing difficulties when you answer these questions.
1- How strong, or loud, was your tinnitus, on average, over the last month? “0” would be “no tinnitus”; “10” would be “the loudest you can imagine.”
0
1
2
3
4
5
6
7
8
9
10
2- How much has tinnitus annoyed you, on average, over the last month? “0” would be “not annoying at all”; “10” would be “as annoying as you can imagine.”
0
1
2
3
4
5
6
7
8
9
10
3- How much did tinnitus affect or impact your life , on average, over the last month? “0” would be “not at all”; “10” would be “extreme effect “.
0
1
2
3
4
5
6
7
8
9
10
Submit
For Hearing Healthcare Professionals
