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Tinnitus Questionnaire

The purpose of the scale is to identify the problems your tinnitus may be causing you. Please select "Yes", “Sometimes”, or “No” for each question. Do not skip a question.

This is a screening mechanism only and should not be considered a substitute for an audiologic evaluation.

* first name

* last name

* email

phone

* 1 Because of your tinnitus is it difficult to concentrate? yes
sometimes
no

* 2 Does the loudness of your tinnitus make it difficult for you to hear people? yes
sometimes
no

* 3 Does your tinnitus make you angry? yes
sometimes
no

* 4 Does your tinnitus make you feel confused? yes
sometimes
no

* 5 Because of your tinnitus do you feel desperate? yes
sometimes
no

* 6 Do you complain a great deal about your tinnitus? yes
sometimes
no

* 7 Because of your tinnitus do you have trouble falling to sleep at night? yes
sometimes
no

* 8 Do you feel that you cannot escape your tinnitus? yes
sometimes
no

* 9 Does your tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the movies)? yes
sometimes
no

* 10 Because of your tinnitus do you feel frustrated? yes
sometimes
no

* 11 Because of your tinnitus do you feel that you have a terrible disease? yes
sometimes
no

* 12 Does your tinnitus make it difficult for you to enjoy life? yes
sometimes
no

* 13 Does your tinnitus interfere with your job or household duties? yes
sometimes
no

* 14 Because of your tinnitus do you find that you are often irritable? yes
sometimes
no

* 15 Because of your tinnitus is it difficult for you to read? yes
sometimes
no

* 16 Does your tinnitus make you upset? yes
sometimes
no

* 17 Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends? yes
sometimes
no

* 18 Do you find it difficult to focus your attention away from your tinnitus and on other things? yes
sometimes
no

* 19 Do you feel that you have no control over your tinnitus? yes
sometimes
no

* 20 Because of your tinnitus do you often feel tired? yes
sometimes
no

* 21 Because of your tinnitus do you feel depressed? yes
sometimes
no

* 22 Does your tinnitus make you feel anxious? yes
sometimes
no

* 23 Do you feel that you can no longer cope with your tinnitus? yes
sometimes
no

* 24 Does your tinnitus get worse when you are under stress? yes
sometimes
no

* 25 Does your tinnitus make you feel insecure? yes
sometimes
no

* 26 Would you like the clinic to contact you? Yes
No

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