Tinnitus Test for Course Participants
What's your email address? (only fill this in if there is no email address)
*
What's your age?
*
Are you a:
*
Woman
Man
Other
Rather not say
When did your tinnitus start (pick closest answer)
A week ago
A month ago
Between 1 and 3 months ago
Between 3 and 6 months ago
Between 6 and 12 months ago
More than 12 months ago
Are you a participant of the Still Tinnitus course?
*
Yes
No
Have you complete the course?
Yes, I've already completed the course
No, I'm not yet finished (I'm testing during the course)
When are you doing this test?
At Step 1 (the beginning of the course)
At Step 5 (the end of the course)
At another moment during the course
When are you taking this test?
*
During the course at Step 1
During the course at Step 5
At another moment during the course
I have already completed the course and I am testing afterwards
Over the past week...
1. What percentage of your time awake were you consciously AWARE of your tinnitus?
*
Never Aware
0
1
2
3
4
5
6
7
8
9
Always Aware
10
0 is Never Aware, 10 is Always Aware
2. How STRONG or LOUD was your tinnitus?
*
Not strong at all
0
1
2
3
4
5
6
7
8
9
Extremely strong or loud
10
0 is Not strong at all, 10 is Extremely strong or loud
3. What percentage of your time awake were you ANNOYED by your tinnitus?
*
None of the time
0
1
2
3
4
5
6
7
8
9
All of the time
10
0 is None of the time, 10 is All of the time
Invasive
4. Did you feel IN CONTROL of your tinnitus?
*
Very much in control
0
1
2
3
4
5
6
7
8
9
Never in control
10
0 is Very much in control, 10 is Never in control
5. How easy was it for you to COPE with your tinnitus?
*
Very easy to cope
0
1
2
3
4
5
6
7
8
9
Impossible to cope
10
0 is Very easy to cope, 10 is Impossible to cope
6. How easy was it for you to IGNORE your tinnitus?
*
Very easy to ignore
0
1
2
3
4
5
6
7
8
9
Impossible to ignore
10
0 is Very easy to ignore, 10 is Impossible to ignore
SenseofControl
Over the past week, how often did your tinnitus interfere with...
7. Your ability to CONCENTRATE?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
8. Your ability to THINK CLEARLY?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
9. Your ability to FOCUS YOUR ATTENTION on other things beside your Tinnitus?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
Mental
Over the past week...
10. How often did your Tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?
*
Never had any difficulty
0
1
2
3
4
5
6
7
8
9
Always had difficulty
10
0 is Never had any difficulty, 10 is Always had difficulty
11. How often did your Tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?
*
Never had any difficulty
0
1
2
3
4
5
6
7
8
9
Always had difficulty
10
0 is Never had any difficulty, 10 is Always had difficulty
12. How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?
*
None of the time
0
1
2
3
4
5
6
7
8
9
All of the time
10
0 is None of the time, 10 is All of the time
Sleep
Over the past week, how often did your tinnitus interfere with...
13. Your ability to HEAR CLEARLY?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
14. Your ability to UNDERSTAND PEOPLE who are talking?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
15. Your ability to FOLLOW CONVERSATIONS in a group or at meetings?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
Hearing
16. Your QUIET RESTING ACTIVITIES?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
17. Your ability to RELAX?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
18. Your ability to enjoy "PEACE AND QUIET"?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
Relaxation
19. Your enjoyment of SOCIAL ACTIVITIES?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
20. Your ENJOYMENT OF LIFE?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
21. Your RELATIONSHIPS with friends, family and other people?
*
Did not interfere
0
1
2
3
4
5
6
7
8
9
Completely interfered
10
0 is Did not interfere, 10 is Completely interfered
22. How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, school work or caring for children or others?
*
Never had any difficulty
0
1
2
3
4
5
6
7
8
9
Always had difficulty
10
0 is Never had any difficulty, 10 is Always had difficulty
QualityofLife
Over the past week...
23. How ANXIOUS or WORRIED has your tinnitus made you feel?
*
Not anxious or worried at all
0
1
2
3
4
5
6
7
8
9
Extremely anxious or worried
10
0 is Not anxious or worried at all, 10 is Extremely anxious or worried
24. How BOTHERED or UPSET have you been because of your tinnitus?
*
Not at all bothered or upset
0
1
2
3
4
5
6
7
8
9
Extremely bothered or upset
10
0 is Not at all bothered or upset, 10 is Extremely bothered or upset
25. How DEPRESSED were you because of your tinnitus?
*
Not at all depressed
0
1
2
3
4
5
6
7
8
9
Extremely depressed
10
0 is Not at all depressed, 10 is Extremely depressed
Emotions
Result
*
Recommendation
*
Total %
*
Resultaat categorie?
Not a problem
Small problem
Moderate problem
Big problem
Very big problem
SUBMIT
DO NOT CLICK 'COMPLETE AND CONTINUE" BELOW BEFORE CLICKING THE SUBMIT button above!
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