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Tinnitus Questionnaire

The purpose of the scale is to identify any problems caused by your tinnitus. Print this form. Circle “Yes,” “Sometimes,” or “No” for each question. Bring the completed form to your visit.


Name_________________________________________________   Date_______________            


1. Because of your tinnitus is it difficult to concentrate? Yes Sometimes No
2. Does the loudness of your tinnitus make it difficult for you to hear people? Yes Sometimes No
3. Does your tinnitus make you angry? Yes Sometimes No
4. Does your tinnitus make you feel confused? Yes Sometimes No
5. Because of your tinnitus do you feel desperate?   Yes Sometimes No
6. Do you complain a great deal about your tinnitus?   Yes Sometimes No
7. Because of your tinnitus do you have trouble falling to sleep at night?  Yes Sometimes No
8. Do you feel you cannot escape your tinnitus? Yes Sometimes No
9. Does your tinnitus interfere with your ability to enjoy social activities (e.g., going out to dinner, to the movies)? Yes Sometimes No
10. Because of your tinnitus do you feel frustrated? Yes Sometimes No
11. Because of your tinnitus do you feel you have a terrible disease? Yes Sometimes No
12. Does your tinnitus make it difficult for you to enjoy life? Yes Sometimes No
13. Does your tinnitus interfere with your job or household duties? Yes Sometimes No
14. Because of your tinnitus do you find you are often irritable? Yes Sometimes No
15. Because of your tinnitus is it difficult for you to read? Yes Sometimes No
16. Does your tinnitus make you upset? Yes Sometimes No
17. Do you feel your tinnitus problem has placed stress on your relationship with members of your family and friends? Yes Sometimes No
18. Do you find it difficult to focus your attention away from your tinnitus and on other things? Yes Sometimes No
19. Do you feel you have no control over your tinnitus? Yes Sometimes No
20. Because of your tinnitus do you often feel tired? Yes Sometimes No
21. Because of your tinnitus do you feel depressed? Yes Sometimes No
22. Does your tinnitus make you feel anxious? Yes Sometimes No
23. Do you feel you can no longer cope with your tinnitus? Yes Sometimes No
24. Does your tinnitus get worse when you are under stress? Yes Sometimes No
25. Does your tinnitus make you feel insecure?   Yes Sometimes No

Reference : McCombe, A., Bagueley, D., Coles, R., McKenna, L., McKinney, C. & Windle-Taylor, P. (1001), Guidelines for the grading of tinnitus severity : the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999, Clin Otolaryngol 26, 388-393.