TINNITUS QUESTIONNAIRE
Please complete the fields with asterisks * at the top of the form
Name:
Address:
Post Code:
*
Date of Birth:
*
Sex:
M
F
*
Email:
Question
Always
Sometimes
Never
1.
I can't ignore the noises
2.
I wake more in the night because of the noises
3.
I have more difficulty following a conversation because of the noises
4.
I find it hard to concentrate because of the noises
5.
I wake earlier in the morning because of the noises
6.
The noises distract me from what I am doing
7.
The noises are there all the time
8.
I find it harder to listen on the telephone because of the noises
9.
It takes longer to drop off to sleep because of the noises
10.
I find it hard to listen to several people at once because of the noises
11.
I feel low because of the noises
12.
The noises are aggravated by some things I eat or drink
13.
The noises are worse after I've been around loud noise
14.
No-one understands about the noises
15.
The noises are worse when I'm feeling low
16.
Loud sounds really annoy me
17.
Stress makes the noises worse