Tinnitus Handicap Inventory Questionnaire

Tinnitus Handicap Inventory Questionnaire

P: (207) 872-0320 F: (207) 872-0330
Name:

First Name Last Name
INSTRUCTIONS: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your tinnitus. Please answer every question. Please do not skip any questions.
Because of your tinnitus, is it difficult for you to concentrate?

Left Sometimes No
Does the loudness of your tinnitus make it difficult for you to hear people?

Left Sometimes No
Does your tinnitus make you angry?

Left Sometimes No
Does your tinnitus make you feel confused?

Left Sometimes No
Because of your tinnitus, do you feel desperate?

Left Sometimes No
Do you complain a great deal about your tinnitus?

Left Sometimes No
Because of your tinnitus, do you have trouble falling asleep at night?

Left Sometimes No
Do you feel as though you cannot escape your tinnitus?

Left Sometimes No
Does your tinnitus interfere with your ability to enjoy social activities? (Such as going out to dinner, to the movies, etc)

Left Sometimes No
Because of your tinnitus, do you feel frustrated?

Left Sometimes No
Because of your tinnitus, do you feel that you have a terrible disease?

Left Sometimes No
Does your tinnitus make it difficult for you to enjoy life?

Left Sometimes No
Does your tinnitus interfere with your job or household responsibilities?

Left Sometimes No
Because of your tinnitus, do you find that you are often irritable?

Left Sometimes No
Because of your tinnitus, is it difficult for you to read?

Left Sometimes No
Does your tinnitus make you upset?

Left Sometimes No
Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends?

Left Sometimes No
Do you find it difficult to focus your attention away from your tinnitus on other things?

Left Sometimes No
Do you feel that you have no control over your tinnitus?

Left Sometimes No
Because of your tinnitus, do you often feel tired?

Left Sometimes No
Because of your tinnitus, do you feel depressed?

Left Sometimes No
Does your tinnitus make you feel anxious?

Left Sometimes No
Does your tinnitus make you feel anxious?

Left Sometimes No
Does your tinnitus get worse when you are under stress?

Left Sometimes No
Does your tinnitus make you feel insecure?

Left Sometimes No
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform