Tinnitus Questionnaire

Tinnitus Questionnaire

 

Name:   ___________________________________________    Date:  ___________________

Tinnitus is the abnormal sensation of sound in the head or ears.
Describe your tinnitus.  ________________________________________________________________________________________________________________________________________________________

1. Where do you have tinnitus?
 Both ears equally  Both ears but not equally:
 In head  Right ear only  Left ear only

2. How long have you had tinnitus?
 Less than 1 year  1-2 years  Over 2 years

3. Was there a particular incident you think caused the tinnitus?  ________________________________________________________________________________________________________________________________________________________

4. How much time passed between that incident and when your tinnitus
began?  ________________________________________________________________________________________________________________________________________________________

5. Has your tinnitus changed since it first started?  Yes  No
Describe:  ________________________________________________________________________________________________________________________________________________________

6. Does your tinnitus remain constant or fluctuate?
 Remains fairly constant  Fluctuates hourly or daily

7. If it fluctuates, how often and to what extent?  ________________________________________________________________________________________________________________________________________________________

8. Rate the severity of your tinnitus:
 1 (mild)  2  3  4  5  6  7  8  9  10 (severe)

9. Are there times when your tinnitus is more likely to occur?
 Always
 During the day  At night
 When stressed/tense/nervous  When tired
 When relaxed  After drinking alcohol
 After smoking  During and/or after exercise
 After loud noise exposure  After consuming caffeine
 During allergies:
 After taking medication:
 After eating:
 Other:

10. Estimate the pitch of your tinnitus:
 1 (low)  2  3  4  5  6  7  8  9  10 (high)

11. Is the loudness of your tinnitus steady or does it pulsate?
 Steady  Pulsates

12. Describe the sound of your tinnitus:
 Hissing  Chirping  Beating/Pulsating/Pounding
 Whistling  Ringing  Clanging  Roaring
 Voices  Other:

13. How often do you smoke?
 0-1 time per day  2-5 times per day  Over 5 times per day

14. How often do you drink caffeinated coffee, tea or soda?
 0-1 time per day  2-3 times per day  Over 3 times per day

15. Have you ever had a head injury?  Yes  No
Describe: ________________________________________________________________________________________________________________________________________________________

16. Have you been exposed to loud sounds (loud enough that you have to
shout for someone to hear you at arm’s length)?  Yes  No
Describe:  ________________________________________________________________________________________________________________________________________________________

17. Do you wear ear protection during loud sounds?  Yes  No

18. Does anything give you relief from your tinnitus?  Yes  No
Describe:  ________________________________________________________________________________________________________________________________________________________

19. Do you have a feeling of fullness in your ears?  Yes  No
Does the feeling change with your tinnitus?  Yes  No

20. Do you have dizziness?  Yes  No
Does the dizziness change with your tinnitus?  Yes  No

21. Are you currently taking any prescription or over-the counter
medications? Describe all your medications including aspirin and
aspirin-containing products:  ________________________________________________________________________________________________________________________________________________________

22. Are you currently taking any vitamins, minerals or herbal
supplements? Describe:  ________________________________________________________________________________________________________________________________________________________

23. Describe any additional information you think Hear Here Audiology should
know:  ________________________________________________________________________________________________________________________________________________________

Hear Here Audiology (727) 289-1212 Phone

502 Pasadena Ave. S.

St. Petersburg, FL 33707

Appointment Booking

info@hearherefl.com

727-289-1212

Call us today!

Office Hours

Mon - Fri: 8:30 - 4:30 PM
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