Tinnitus Severity Assessment Form
Please complete this form to help us evaluate the severity and impact of your tinnitus. Your responses will assist in providing the most appropriate care.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
How long have you experienced tinnitus?
*
Please Select
Less than 3 months
3–12 months
1–5 years
More than 5 years
How would you describe the sound of your tinnitus?
*
Ringing
Buzzing
Hissing
Clicking
Roaring
Other
On which side do you perceive tinnitus?
*
Left ear
Right ear
Both ears
Inside the head
Please rate the average loudness of your tinnitus (1 = very quiet, 10 = extremely loud).
*
Very quiet
1
2
3
4
5
6
7
8
9
Extremely loud
10
1 is Very quiet, 10 is Extremely loud
Tinnitus Impact Assessment
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty sleeping
1
2
3
4
5
Difficulty concentrating
6
7
8
9
10
Irritability or mood changes
11
12
13
14
15
Interference with daily activities
16
17
18
19
20
Feeling anxious or stressed
21
22
23
24
25
How much does tinnitus affect your quality of life?
*
1
2
3
4
5
Have you tried any treatments or coping strategies for tinnitus? If yes, please specify.
Do you have any hearing loss?
*
Yes
No
Not sure
Please provide any additional information you think is relevant.
Submit Assessment
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