How does Tinnitus Impact Your Life?

April 28, 2020

This self-assessment, reaction questionnaire is designed to find out what sort of effects tinnitus has had on your lifestyle, general well-being, etc.

Some of the effects below may apply to you, some may not.

Please answer all questions by selecting the number that
best reflects how your tinnitus has affected you over the past week.

Rank your responses from 0 – Not at all to 4 – Almost all of the time

Tinnitus 2021

Name
First Last
Phone
Email
My tinnitus has made me unhappy.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me tense.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel irritable.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel angry.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me to cry.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me to avoid quite situations.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me feel less interested in going out.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel depressed.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel annoyed.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel confused.
- 0
- 1
- 2
- 3
- 4
My tinnitus has "driven me crazy".
- 0
- 1
- 2
- 3
- 4
My tinnitus has interfered with my enjoyment of life.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made it hard for me to relax.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel distressed.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel helpless.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel frustrated with things.
- 0
- 1
- 2
- 3
- 4
My tinnitus has interfered with my ability to work.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me to despair.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me to avoid social situations.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel hopeless about the future.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made interfered with my sleep.
- 0
- 1
- 2
- 3
- 4
My tinnitus has led me to think about suicide.
- 0
- 1
- 2
- 3
- 4
My tinnitus has made me feel tormented.
- 0
- 1
- 2
- 3
- 4
TOTAL
Name
This field is for validation purposes and should be left unchanged.

SCORE RESULTS
0-46
Your results show you either have no or little signs tinnitus is currently interfering with your life. Over time, you may want to take the assessment again to see if things change. If you do have concerns, please discuss them with us during your next hearing exam. This is simply a self-assessment. During your appointment, we will conduct a more thorough and complete assessment. Call our office to schedule an appointment today (423) 641-0956.

47-92
Your results have indicated you experience a moderate to a significant negative impact on your life from tinnitus. Please call our office to schedule an appointment (423) 641-0956. Along with baseline or updated hearing evaluation, we can discuss potential treatment options that may offer you some relief. We would be honored to help you.

If you have ranked any of these questions with a high score, call our office at 423-641-0956 if you would like to schedule an appointment for a more thorough assessment.

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