ADULT Tinnitus & Hyperacusis Questionnaire ADULT Tinnitus & Hyperacusis QuestionnaireClient NameDate MM slash DD slash YYYY HiddenChoose one Initial Follow Up FinalTHI1. 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 No25. Does your Tinnitus make you feel insecure? Yes Sometimes NoMKHQ - AdultThese questions are about EVERYDA Y & ENVIRONMENTAL SOUNDS (not tinnitus)1. Do you have trouble concentrating in a noisy or loud environment? Yes Sometimes No2. Do you have trouble reading in a noisy or loud environment? Yes Sometimes No3. Do you ever use earplugs or earmuffs to reduce your noise perception? (Do not consider the use of hearing protection during abnormally high exposure situations.) Yes Sometimes No4. Do you find it harder to ignore sounds around you in everyday situations? Yes Sometimes No5. Do you find it difficult to listen to speaker announcements (such as airport, airplanes, trains, etc.)? Yes Sometimes No6. Are you particularly sensitive to or bothered by street noise? Yes Sometimes No7. Do you “automatically” cover your ears in the presence of somewhat louder sounds? Yes Sometimes No8. When someone suggests doing something (going out, to the cinema, to a concert, etc.), do you immediately think about the noise you are going to have to put up with? Yes Sometimes No9. Do you ever turn down an invitation or not go out because of the noise you would have to face? Yes Sometimes No10. Do you find the noise unpleasant in certain social situations (e.g., nightclubs, pubs or bars, concerts, firework displays, cocktail receptions)? Yes Sometimes No11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly? Yes Sometimes No12. Are you particularly bothered by sounds others are not? Yes Sometimes No13. Are you afraid of sounds that others are not? Yes Sometimes No14. Do noise and certain sounds cause you stress and irritation? Yes Sometimes No15. Are you less able to concentrate in noise toward the end of the day? Yes Sometimes No16. Do stress and tiredness reduce your ability to concentrate in noise? Yes Sometimes No17. Do you find sounds annoy you and not others? Yes Sometimes No18. Are you emotionally drained by having to put up with all daily sounds? Yes Sometimes No19. Do you find daily sounds having an emotional impact on you? Yes Sometimes No20. Are you irritated by sounds others are not? Yes Sometimes NoForm completed by Self OtherFullName
