Tinnitus History
Name:
M / F
Date:
Address:
DoB:
Phone:
Home
Work
Email:
[ ] Single
[ ] 8th grade or less
Occupation:
Referred to clinic by:
[ ] Married
[ ] Widowed
Highest level of education completed:
[ ] High School
[ ] Vocational Training
[ ] College
[ ] Graduate School
Spouse’s Name:
Primary Physician:
ENT or Otologist:
Audiologist:
Relative / Friend:
Other:
1. Grade the severity of each of the following based on a scale of 0 - 10 (a “10” being the worst).
Circle your answer and please circle “0” if it does not apply.
Hearing Loss:
0
1
2
3
4
5
6
7
8
9
Tinnitus1:
0
1
2
3
4
5
6
7
8
9
Hyperacusis2:
0
1
2
3
4
5
6
7
8
9
Depression:
0
1
2
3
4
5
6
7
8
9
2. Grade the overall loudness of your most troublesome tinnitus.
[Softest]
0
1
2
3
4
5
6
7
8
3. Grade the impact the tinnitus has on your quality of life using a “0” to “10” scale.
[None]
0
1
2
3
4
5
6
7
8
10
10
10
10
[Loudest]
9
10
[Completely Ruined]
9
10
4. What portion of your waking hours on average are you aware of your tinnitus, even if you do not purposefully
listen for it? (circle one)
>10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5. If you have hyperacusis (sensitivity to everyday sound), grade the impact hyperacusis has on your quality of life:
[None]
[Completely Ruined]
0
1
2
3
4
5
6
7
8
9
10
Tinnitus History Questionnaire
Nature of the Tinnitus
Describe the tinnitus sound: ____________________________________________________________________________________
Please circle the best answer that describes the tinnitus:
Is the tinnitus:
Constant
Does the tinnitus fluctuate in intensity?
Intermittent
Pulsatile
(Rhythmic with heart beat? Y / N )
Yes / No
What makes the tinnitus worse? _________________________________________________________________________________
What makes the tinnitus better? _________________________________________________________________________________
Tinnitus History
Under what circumstances did the tinnitus start? ____________________________________________________________________
____________________________________________________________________
When did the tinnitus first become disturbing? ____________________________________________________________________
____________________________________________________________________
Whom have you consulted regarding your tinnitus? __________________________________________________________________
__________________________________________________________________
What have previous medical professionals recommended for your tinnitus issue?
______________________________________________________________________________________________
What treatments have you tried for your tinnitus? (check all that apply)
Ο None
Ο Hearing Aids
Ο Masker
Ο TRT
Ο Music Therapy
Ο Cognitive Behavioral Therapy
Ο Neuromonics
Ο Other: __________________________________________________________________________________
How successful did you find any of these treatments? __________________________________________________
Tinnitus History Questionnaire
Name:
DOB:
Date:
Have you ever:
- Been exposed to gunfire or explosion?
- Attended loud events (e.g. music concerts or clubs)?
- Had any noisy jobs?
- Had any noisy hobbies or home activities?
- Had any head injuries or concussions?
- Had any operations involving your ear or head?
- Taken any of the following medications: Quinine, Quindidine, Streptomycin,
Kantamycin, Dihydrostreptomycin, Neomycin, Used solvents, thinners, or alcohol
based cleaners? (If so, please circle the appropriate medication)
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Do you:
- Have loose dentures, jaw pain, or grinding and clicking sensations in the jaw?
- Regularly take Aspirin or Dispirin?
- Have any feelings of ear pressure or blockage?
- Find exposure to moderately loud sounds makes your tinnitus worse?
Y/N
Y/N
Y/N
Y/N
General Hearing Problems
Do you:
- Have difficulties hearing when there is background noise?
- Have difficulties understanding in one-to-one conversations?
- Have difficulties hearing the TV?
- Have difficulties hearing the telephone?
- Have any dizziness or balance problems?
- Find external sounds unpleasant or uncomfortable?
- Dislike certain external sounds?
- Wear ear protections / ear plugs?
Is hearing loss more troublesome than tinnitus?
Details / Comments:
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Tinnitus History Questionnaire
Name:
DOB:
Date:
Effects of the Tinnitus
- Over the past week, what percentage were you aware of your tinnitus
(e.g. 100% aware all the time, 25% aware ¼ of the time)?
- What percentage of the time was it disturbing?
- Does your tinnitus prevent you from getting to sleep at night?
- How many times per night did you awake in the last week?
%
%
Y/N
How has tinnitus affected your work life?
How has tinnitus affected your home life?
How has tinnitus affected your social activities?
General Health
What is your general health like?
Are you taking any medications? (If yes, please specify)
Compensation
Are you currently pursuing any form of compensation, sickness benefit, DVA, motor vehicle
accident claim, or any other legal action in relation to your tinnitus? _______________
Medical Contact Details
Name and address of GP:
Name and address of ENT:
I give consent to release results to my
GP / ENT
Signed: ______________________________
Date: ___________
Is there anything else you would like to add that might be relevant to understanding what caused
your tinnitus?
Tinnitus Reaction Questionnaire
Name:
Date:
This questionnaire is designed to find out what sort of effects tinnitus has had on your lifestyle,
general well-being, etc. Some of the effects below may apply to you, some may not. Please answer
all questions by circling the number that best reflects how your tinnitus has affected you over the
past week.
Not at
all
1. My tinnitus has made me unhappy.
2. My tinnitus has made me feel tense.
3. My tinnitus has made me feel irritable.
4. My tinnitus has made me feel angry.
5. My tinnitus has led me to cry.
6. My tinnitus has led me to avoid quiet situations.
7. My tinnitus has made me feel less interested in
going out.
8. My tinnitus has made me feel depressed.
9. My tinnitus has made me feel annoyed.
10. My tinnitus has made me feel confused.
11. My tinnitus has “driven me crazy”.
12. My tinnitus has interfered with my enjoyment of life.
13. My tinnitus has made it hard for me to concentrate.
14. My tinnitus has made it hard for me to relax.
15. My tinnitus has made me feel distressed.
16. My tinnitus has made me feel helpless.
17. My tinnitus has made me feel frustrated with things.
18. My tinnitus has interfered with my ability to work.
19. My tinnitus has led me to despair.
20. My tinnitus has led me to avoid noisy situations.
21. My tinnitus has led me to avoid social situations.
22. My tinnitus has made me feel hopeless about the
future.
23. My tinnitus has interfered with my sleep.
24. My tinnitus has led me to think about suicide.
25. My tinnitus has made me feel panicky.
26. My tinnitus has made me feel tormented.
Total
0
0
0
0
0
0
A little
of the
time
1
1
1
1
1
1
Some
of the
time
2
2
2
2
2
2
Most
of the
time
3
3
3
3
3
3
All of
the
time
4
4
4
4
4
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4