YOUTH Tinnitus & Hyperacusis Questionnaire

Calgary403-270-7425
Grande Prairie780-538-2744
High River403-652-7721
Lethbridge1-866-402-5552

Client Name
Date
MM slash DD slash YYYY
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- Initial
- Follow Up
- Final
THI-Youth
1. Because of your Tinnitus is it difficult for you 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 confused?
- Yes
- Sometimes
- No
5. Because of your Tinnitus are you 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 asleep at night?
- Yes
- Sometimes
- No
8. Do you feel as though you cannot escape from your Tinnitus?
- Yes
- Sometimes
- No
9. Does your Tinnitus interfere with your ability to enjoy social activities ( going out to movies, being in groups of family or friends )?
- Yes
- Sometimes
- No
10. Because of your Tinnitus do you feel frustrated?
- Yes
- Sometimes
- No
11. Because of your Tinnitus do you feel that you have a terrible disease?
- Yes
- Sometimes
- No
12. Does your Tinnitus make it difficult to enjoy life?
- Yes
- Sometimes
- No
13. Does your Tinnitus interfere with school or household responsibilities?
- Yes
- Sometimes
- No
14. Because of your Tinnitus do you find that 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 that your Tinnitus has placed stress on your relationships 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 to other things?
- Yes
- Sometimes
- No
19. Do you feel that 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
MKHQ-Youth
These questions are about EVERYDA Y & ENVIRONMENTAL SOUNDS (not tinnitus)
1. Do you have trouble concentrating in a noisy or loud environment?
- Yes
- Sometimes
- No
2. Do you have trouble reading in a noisy or loud environment?
- Yes
- Sometimes
- No
3. 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
- No
4. Do you find it harder to ignore sounds around you in everyday situations?
- Yes
- Sometimes
- No
5. Do you find it difficult to listen to speaker announcements ( school, stores .)?
- Yes
- Sometimes
- No
6. Are you particularly sensitive to or bothered by street noise?
- Yes
- Sometimes
- No
7. Do you “automatically” cover your ears in the presence of somewhat louder sounds?
- Yes
- Sometimes
- No
8. When someone suggests doing something ( movies, malls, restaurants) do you immediately think about the noise you are going to have to put up with?
- Yes
- Sometimes
- No
9. Do you ever turn down an invitation or not go out because of the noise you would have to face?
- Yes
- Sometimes
- No
10. Do you find the noise unpleasant in certain social situations (birthday parties, school assemblies, firework displays, big family get-togethers)?
- Yes
- Sometimes
- No
11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly?
- Yes
- Sometimes
- No
12. Are you particularly bothered by sounds others are not?
- Yes
- Sometimes
- No
13. Are you afraid of sounds that others are not?
- Yes
- Sometimes
- No
14. Do noise and certain sounds cause you stress and irritation?
- Yes
- Sometimes
- No
15. Are you less able to concentrate in noise toward the end of the day?
- Yes
- Sometimes
- No
16. Do stress and tiredness reduce your ability to concentrate in noise?
- Yes
- Sometimes
- No
17. Do you find sounds annoy you and not others?
- Yes
- Sometimes
- No
18. Are you emotionally drained by having to put up with all daily sounds?
- Yes
- Sometimes
- No
19. Do you find daily sounds having an emotional impact on you?
- Yes
- Sometimes
- No
20. Are you irritated by sounds others are not?
- Yes
- Sometimes
- No
Form completed by
- Self
- Other
FullName

YOUTH Tinnitus & Hyperacusis Questionnaire

THI-Youth

MKHQ-Youth

These questions are about EVERYDA Y & ENVIRONMENTAL SOUNDS (not tinnitus)

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