Veterans Disability Tinnitus Evaluation Questionnaire Form
Please complete this assessment to help us understand your tinnitus experience. All questions are required for a thorough evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How long have you experienced tinnitus?
*
Please Select
Less than 6 months
6–12 months
1–3 years
More than 3 years
How would you describe the frequency of your tinnitus?
*
Constant
Intermittent
Occasional
How severe is your tinnitus on most days?
*
Not severe
1
2
3
4
5
6
7
8
9
Extremely severe
10
1 is Not severe, 10 is Extremely severe
Which ear is affected?
*
Left ear
Right ear
Both ears
Uncertain
How does tinnitus affect your daily activities?
*
Difficulty sleeping
Trouble concentrating
Emotional distress
Interference with work
No significant impact
Other
Have you received any treatment for your tinnitus?
*
Yes
No
Please provide any additional details about your tinnitus experience.
Submit Evaluation
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