This form collects information about the needs of people with tinnitus and will help us to plan and provide tinnitus services.
*Your name and address are optional - however please provide your email, postcode, date of birth and sex.
 
               
  Name: *
Email:
  Address: *
  Post Code:
  Date of Birth:
  Sex: M F
     
   
  How did you hear about Tinnitus SA?
 
       
  Dr or other professional
  Hearing service provider/Audiologist:
  Tinnitus SA poster, brochure
  Print Ad
  Yellow Pages
  Friend
  Hearing or Tinnitus group
  Other: Please describe
   
     
               
Are you a:
 
       
  Tinnitus Sufferer
  Family member or friend of someone with tinnitus
  Professional
     
 
  If you are a tinnitus sufferer, please answer the following questions:
 
         
  Are you of Aboriginal or Torres Strait Islander orgin?     Yes No
       
  Is English your first language?   Yes No *
               
  * Spoken language  
               
  Do you receive a pension?   Yes No
       
  Do you have a health care card?   Yes No
       
  How long have you had tinnitus?  
       
  How did it start?   Suddenly Gradually
       
  Where is your tinnitus?  

Right ear
Left ear
Both ears
Head

       
  Is it   intermittent constant
       
  Please rate your tinnitus severity from 0 to 10 = "as severe as you can imagine"  
       
 
Activities prevented or affected by tinnitus:
 
       
    Concentration
    Sleep
    QRA (quiet recreational activities)
    Work
    Restaurants
    Sports
    Social
    Other
       
  Are you sensitive to or intolerant of loud sounds?   Yes No
       
  Have you:
Seen an ENT?		    
    Yes No
  Had a hearing test?   Yes No
  Any hearing loss?   Yes No
       
  Do you or have you worn a hearing aid?   Yes No
       
  What type of treatment have you had for your condition?  
       
  What helps to give you relief?  
          
   
  Please indicate the sevice(s) you'd like :
   
       
    to receive a printed information information pack
      to receive specific information sheets
     
  3. Flying, Diving & Tinnitus
  5. Drugs, Food & Tinnitus 
  6. Illnesses & Tinnitus
  19. Compliments and Complaints
   
 
 
 
 
 
    to register to attend a community infomation session