Adult Tinnitus Questionaire Adult Tinnitus QuestionaireNameDate of Birth MM slash DD slash YYYY Location for which you are filling the formChoose locationCalgaryHigh RiverLethbridgeGrande PrairieForm completed for Self Parent Other1. Because of your Tinnitus is it difficult for you to concentrate? Yes Sometimes No2. Does the loudness of your Tinnitus make it difficult for you to hear people? Yes Sometimes No3. Does your Tinnitus make you angry? Yes Sometimes No4. Does your Tinnitus make you confused? Yes Sometimes No5. Because of your Tinnitus are you desperate? Yes Sometimes No6. Do you complain a great deal about your Tinnitus? Yes Sometimes No7. Because of your tinnitus do you have trouble falling asleep at night? Yes Sometimes No8. Do you feel as though you cannot escape from your Tinnitus? Yes Sometimes No9. Does your Tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the cinema)? Yes Sometimes No10. Because of your Tinnitus do you feel frustrated? Yes Sometimes No11. Because of your Tinnitus do you feel that you have a terrible disease? Yes Sometimes No12. Does your Tinnitus make it difficult to enjoy life? Yes Sometimes No13. Does your Tinnitus interfere with your job or household responsibilities? Yes Sometimes No14. Because of your Tinnitus do you find that you are often irritable? Yes Sometimes No15. Because of your Tinnitus is it difficult for you to read? Yes Sometimes No16. Does your Tinnitus make you upset? Yes Sometimes No17. Do you feel that your Tinnitus has placed stress on your relationships with members of your family and friends? Yes Sometimes No18. Do you find it difficult to focus your attention away from your Tinnitus and on to other things? Yes Sometimes No19. Do you feel that you have no control over your Tinnitus? Yes Sometimes No20. Because of your Tinnitus do you often feel tired? Yes Sometimes No21. Because of your Tinnitus do you feel depressed? Yes Sometimes No22. Does your Tinnitus make you feel anxious? Yes Sometimes No23. Do you feel you can no longer cope with your Tinnitus? Yes Sometimes No24. Does your Tinnitus get worse when you are under stress? Yes Sometimes NoPlease read each question below carefully. To answer a question, select ONE of the numbers that is listed for that question.(I) Over the past week ….1. What percentage of your time awake were you consciously AWARE OF your tinnitus?Select your choiceNever aware0%10%20%30%40%50%60%70%80%90%100%Always aware2. How STRONG or LOUD was your tinnitus?Select your choiceNot at all strong or loud012345678910Extremely strong or loud3. What percentage of your time awake were you ANNOYED by your tinnitus?Select your choiceNone of the time0%10%20%30%40%50%60%70%80%90%100%All of the time(SC) Over the past week ….4. Did you feel IN CONTROL in regard to your tinnitus?Select your choiceVery much in control012345678910Never in control5. How easy was it for you to COPE with your tinnitus?Select your choiceVery easy to cope012345678910Impossible to cope6. How easy was it for you to IGNORE your tinnitus?Select your choiceVery easy to ignore012345678910Impossible to ignore(C) Over the past week how much has your tinnitus interfered with …7. Your ability to CONCENTRATE?Select your choiceDid not interfere012345678910Completely interfered8. Your ability to THINK CLEARLY?Select your choiceDid not interfere012345678910Completely interfered9. Your ability to FOCUS ATTENTION on other things besides your tinnitus?Select your choiceDid not interfere012345678910Completely interfered(SL) Over the past week ….10. How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?Select your choiceNever had difficulty012345678910Always had difficulty11. How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?Select your choiceNever had difficulty012345678910Always had difficulty12. How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?Select your choiceNone of the time012345678910All of the time(A) Over the past week how much has your tinnitus interfered with …..13. Your ability to HEAR CLEARLY?Select your choiceDid not interfere012345678910Completely interfered14. Your ability to UNDERSTAND PEOPLE who are talking?Select your choiceDid not interfere012345678910Completely interfered15. Your ability to FOLLOW CONVERSATIONS in a group or at meetings?Select your choiceDid not interfere012345678910Completely interfered(R) Over the past week how much has your tinnitus interfered with …..16. Your QUIET RESTING ACTIVITIES?Select your choiceDid not interfere012345678910Completely interfered17. Your ability to RELAX?Select your choiceDid not interfere012345678910Completely interfered18. Your ability to enjoy “PEACE AND QUIET”?Select your choiceDid not interfere012345678910Completely interfered(Q) Over the past week how much has your tinnitus interfered with …..19. Your enjoyment of SOCIAL ACTIVITIES?Select your choiceDid not interfere012345678910Completely interfered20. Your ENJOYMENT OF LIFE?Select your choiceDid not interfere012345678910Completely interfered21. Your RELATIONSHIPS with family, friends and other people?Select your choiceDid not interfere012345678910Completely interfered21. Your RELATIONSHIPS with family, friends and other people?Select your choiceDid not interfere012345678910Completely interfered22. How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, school work, or caring for children or others?Select your choiceDid not interfere012345678910Completely interfered(E) Over the past week ….23. How ANXIOUS or WORRIED has your tinnitus made you feel?Select your choiceNot at all anxious or worried012345678910Extremely anxious or worried24. How BOTHERED or UPSET have you been because of your tinnitus?Select your choiceNot at all bothered or upset012345678910Extremely bothered or upsetAny Additional Comments:Select your choiceNot at all depressed012345678910Extremely depressed25. How DEPRESSED were you because of your tinnitus?Select your choiceNot at all depressed012345678910Extremely depressedAny Additional Comments:
