Tinnitus Questionnaire

Patient Name:

Patient Age:

Date:

Address:

Phone:

I have had tinnitus in its present form for:
Less than a yearOne to two yearsTwo to three yearsThree to five yearsLonger than five years

Prior to my present form of tinnitus, I had a mild tinnitus for (length of time):

My tinnitus seems to be primarily located in:
the left earthe right earboth ears equallyboth ears but unequalmy head

The severity of my tinnitus in its worse form, according to the scale below, is represented by the The severity of my tinnitus in its worse form, according to the scale below:
MildModeratelyExtremely SevereSevere

The loudeness of my tinnitus is:
Fairly constant from day to dayFluctuates widely being very loud on some days and very mild on other daysUsually constant but on rare occasions will decrease markedly

On the scale below, indicate the pitch of your tinnitus. It might help to imagine the scale as if it were a piano keyboard.
Low PitchMiddle PitchHigh Pitch

Check any items below which describe how your tinnitus sounds:
hissingringingcricket-likeSteam whistlePoundingBellsPulsatingClangingWhistleOcean roaringOther

My tinnitus appears worse: (circle the appropriate letter)
When I am tiredWhen I am tense and nervousWhen I am relaxedAfter use of alcohol

Do you smoke?
YesNo

Do you drink coffee?
YesNo

Check any of the following items which give you any relief from your tinnitus.
Listening to radio or T.V.Traffic soundsSounds of running water (e.g. shower)MedicationOther

Have you ever experienced a head injury?
YesNo

Have you been exposed to loud sounds?
YesNo

Are you presently working in or exposed to loud sounds?
YesNo

Do you wear ear protection in the presence of loud sounds?
YesNo