Name: Date: Address: E-Mail: Age: Phone Home: Sex Male Female Phone Work: Occupation: Marital Statut: Single Married Divorced
Please check the appropriate boxes:
Tinnitus Location? right ear Left ear Both ears In the head Tinnitus Onset? Gradual onset Sudden onset Approximative date Tinnitus Course? has stayed about the same has become somewhat worse has become much worse has become better
Possible tinnitus cause? ear infection ear surgery sudden hearing loss sudden intense noise head injury long term noise Other illness drug or medication Tinnitus characteristics? steady tone changing tone ringing steady noise hissing buzzing hum pulsating Other roar heart beat crackeling Are you bothered by loud sounds? Yes No Is it mild moderate severe or unbearable ?
Severity of tinnitus: What do you rate your tinnitus? Choose a number for each question. None 1 2 3 4 5 6 7 8 9 10 Slight 1 2 3 4 5 6 7 8 9 10 Moderate 1 2 3 4 5 6 7 8 9 10 Severe 1 2 3 4 5 6 7 8 9 10 Worst 1 2 3 4 5 6 7 8 9 10
	The most severe level of my tinnitus is
	My tinnitus level right now is
The amount of interference during? working sleeping concentrating relaxing socializing Other
How do you rate your life? OK pleasant very unpleasant very pleasant do not care
How do you rate your stress level? very low low average high very high Do you consider yourself emotionally stable? Yes No If not, are you under medication? Yes No
How do you describe your tinnitus overly? Check all that applies: mild annoying troublesome distressing irritating interfering dreadful miserable intense discomforting horrible agonizing torturing unbearable excruciating worst possible Other
Effect on tinnitus: My tinnitus is worse when? I'm tired tense or nervous relaxing lying down in bed at night under stress Other
What does help your tinnitus? Sound of water traffic sound listening to TV Other drugs hearing aid changes in altitude
What type of treatment have you used? Has it helped? Yes No Somewhat What are you using now? For how long? What concerns you most about your tinnitus?

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