Barcode
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Please answer the following questions based on your experience over the PAST WEEK
1. Over the
PAST WEEK
what percentage of your time awake were you consciously
AWARE OF
your tinnitus?
*
*
3.What percentage of your time awake were you
ANNOYED
by your tinnitus?
*
4.Over the
PAST WEEK
did you feel
IN CONTROL
in regard to your tinnitus?
*
5. Over the
PAST WEEK
, how easy was it for you to
COPE
with your tinnitus?
*
6. Over the
PAST WEEK
how easy was it for you to
IGNORE
your tinnitus?
*
7. Over the
PAST WEEK
how did your tinnitus affect your ability to
CONCENTRATE
?
*
8. Over the PAST WEEK how did your tinnitus affect your ability to
THINK CLEARLY
?
*
9. Over the
PAST WEEK
how did your tinnitus affect your ability to
FOCUS ATTENTION
on other things besides your tinnitus?
*
10. Over the
PAST WEEK
, how often did your tinnitus make it difficult to
FALL ASLEEP
or
STAY ASLEEP
?
*
11. Over the
PAST WEEK
, how often did your tinnitus make it difficult to
FALL ASLEEP
or
STAY ASLEEP
?
*
12. Over the
PAST WEEK
, how much of the time did your tinnitus keep you from
SLEEPING
as
DEEPLY
or as
PEACEFULLY
as you would have liked?
*
13. Over the
PAST WEEK
how much has your tinnitus interfered with your ability to
HEAR CLEARLY
?
*
14. Over the
PAST WEEK
how much has your tinnitus interfered with your ability to
UNDERSTAND PEOPLE
who are talking?
*
15. Over the
PAST WEEK
how much has your tinnitus interfered with your ability to
FOLLOW CONVERSATIONS
in groups or in meetings?
*
16. Over the
PAST WEEK
how much has your tinnitus interfered with your
QUIET RESTING ACTIVITIES
?
*
17. Over the
PAST WEEK
how much has your tinnitus interfered with your ability to
RELAX
?
*
18. Over the
PAST WEEK
how much has your tinnitus interfered with your ability to enjoy “
PEACE AND QUIET
”?
*
19. Over the
PAST WEEK
how much has your tinnitus interfered with your enjoyment of
SOCIAL ACTIVITIES
?
*
20. Over the
PAST WEEK
how much has your tinnitus interfered with your
ENJOYMENT OF LIFE
?
*
21. Over the
PAST WEEK
how much has your tinnitus interfered with your
RELATIONSHIPS
with family, friends, and other people?
*
22. Over the
PAST WEEK
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?
*
23. Over the
PAST WEEK
how
ANXIOUS
or
WORRIED
has your tinnitus made you feel?
*
24. Over the
PAST WEEK
how
BOTHERED
or
UPSET
have you been because of your tinnitus?
*
25. Over the
PAST WEEK
how
DEPRESSED
were you because of your tinnitus?
*
Submit
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