Tinnitus Evaluation Intake Questionnaire
Please complete this questionnaire to help us better understand your tinnitus symptoms and their impact on your life.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
How long have you been experiencing tinnitus?
*
Less than 1 month
1-6 months
6-12 months
More than 1 year
How would you describe the sound of your tinnitus?
*
Ringing
Buzzing
Hissing
Clicking
Roaring
Other
On a scale of 1 to 10, how severe is your tinnitus?
*
Not severe
1
2
3
4
5
6
7
8
9
Extremely severe
10
1 is Not severe, 10 is Extremely severe
How does tinnitus affect the following aspects of your life?
*
Rows
Not at all
A little
Moderately
Severely
Sleep
1
2
3
4
Concentration
5
6
7
8
Mood
9
10
11
12
Social interactions
13
14
15
16
Do you experience any of the following with your tinnitus?
Hearing loss
Ear pain
Dizziness
Fullness in the ear
None of the above
Have you been exposed to loud noise regularly?
Yes
No
Do you have a history of ear infections or ear diseases?
Yes
No
Please share any additional information or comments about your tinnitus.
Submit
Should be Empty: