Name/ID:		Date:
INSTRUCTIONS: The purpose of the questionnaire is to identify difficulties that you may be experiencing because of your tinnitus. Please answer YES, SOMETIMES, or NO to each question. Please do not skip any questions.
F-1	Because of your tinnitus, is it difficult for you to concentrate?			Yes Sometimes No
F-2	Does the loudness of your tinnitus make it difficult for you to hear people?			Yes Sometimes No
E-3	Does your tinnitus make you angry?			Yes Sometimes No
F-4	Does your tinnitus make you feel confused?			Yes Sometimes No
C-5	Because of your tinnitus, do you feel desperate?			Yes Sometimes No
E-6	Do you complain a great deal about your tinnitus?			Yes Sometimes No
F-7	Because of your tinnitus, do you have trouble falling asleep at night?			Yes Sometimes No
C-8	Because of your tinnitus, is it difficult for you to concentrate?			Yes Sometimes No
F-9	Does your tinnitus interfere with your ability to enjoy your social activities?			Yes Sometimes No
	(such as going out to dinner, to the movies, etc...)?
E-10	Because of your tinnitus, do you feel frustrated?			Yes Sometimes No
C-11	Because of your tinnitus, do you feel that you have a tremble disease?			Yes Sometimes No
F-12	Does your tinnitus make it difficult for you to enjoy life?			Yes Sometimes No
F-13	Does your tinnitus interfere with your job or household responsabilities?			Yes Sometimes No
E-14	Because of your tinnitus, do you find that you are often irritable?			Yes Sometimes No
F-15	Because of your tinnitus, is it difficult for you to read?			Yes Sometimes No
E-16	Does your tinnitus make you upset?			Yes Sometimes No
E-17	Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?			Yes Sometimes No
F-18	Do you find it difficult to focus your attention away from your tinnitus and on other things?			Yes Sometimes No
C-19	Do you feel that you have no control over your tinnitus?			Yes Sometimes No
F-20	Because of your tinnitus, do you often feel tired?			Yes Sometimes No
E-21	Because of your tinnitus, do you often feel depressed?			Yes Sometimes No
E-22	Does your tinnitus make you feel anxious?			Yes Sometimes No
C-23	Do you feel that you can no longer cope with your tinnitus?			Yes Sometimes No
F-24	Does your tinnitus get you worse when you are under stress?			Yes Sometimes No
E-25	Does your tinnitus make you feel insecure?			Yes Sometimes No

Pre TX:	F	C	E	T
1st Post TX:	F	C	E	T
2nd Post TX:	F	C	E	T

Your information will be kept confidential. We will attempt to reply to your inquiry within 48 hours.