Tinnitus Screening Questionnaire

This assessment is a self-test. The responses can help you to understand what may be happening with your tinnitus. After you complete the assessment, you'll be contacted by email. We will suggest treatment options that fit your profile. All your responses will be stored & handled following our privacy policy.

First name

Last name

Phone

Because of your tinnitus, is it difficult for you to concentrate?

Does the loudness of your tinnitus make it difficult for you to hear people?

Does your tinnitus make you angry?

Does your tinnitus make you feel confused?

Because of your tinnitus, do you feel desperate?

Do you complain a great deal about your tinnitus?

Because of your tinnitus, do you have trouble falling to sleep at night?

Do you feel as though you cannot escape your tinnitus?

Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies)?

Because of your tinnitus, do you feel frustrated?

Because of your tinnitus, do you feel that you have a terrible disease?

Does your tinnitus make it difficult for you to enjoy life?

Does your tinnitus interfere with your job or household responsibilities?

Because of your tinnitus, do you find that you are often irritable?

Because of your tinnitus, is it difficult for you to read?

Does your tinnitus make you upset?

Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?

Do you find it difficult to focus your attention away from your tinnitus and on other things?

Do you feel that you have no control over your tinnitus?

Because of your tinnitus, do you often feel tired?

Because of your tinnitus, do you feel depressed?

Does your tinnitus make you feel anxious?

Do you feel that you can no longer cope with your tinnitus?

Does your tinnitus get worse when you are under stress?

Does your tinnitus make you feel insecure?

Please tell us anything additional you think would be helpful for us to know about your responses. Any other diagnoses? Your work or school setting?

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When did you notice the issues or challenges that brought you here? Please also list any formal evaluations/treatment for tinnitus & your age at the time of these interventions.

Are you interested in more information about...?

Are you located in the United States?

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