Pre-Screening Questionnaire

Pre-Screening Questionnaire
We are an audiology clinic specializing in advanced assessment and non-medical rehabilitation of complex auditory conditions, including tinnitus, sound tolerance disorders, and hearing loss. Due to the complexity of cases we see, this questionnaire is intended to assist our Patient Care Team in determining your candidacy for our services, as well as how best to help you proceed with the assessment stage of our intake process.
Looking for more information?

Our various types of assessments can be viewed HERE.

A general overview of our tinnitus treatment program can be viewed HERE.

A general overview of how we treat sound tolerance disorders (hyperacusis and misophonia) can be viewed HERE.
Basic Personal Information

Your privacy is important to us; your responses are encrypted and secure.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter the best phone number to reach you.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
If you are inquiring on behalf of a child/minor, please provide their date of birth.
1. Please tell us which of the following auditory* conditions are you experiencing (you may select more than one option):*

Hearing lossTinnitus (phantom sounds in your ears/head. This does not include hearing body sounds like your heartbeat/pulse, or your breathing)Sound sensitivities (external sounds are loud to the point of pain/discomfort, or you are overly bothered by specific sounds)Auditory processing problems (Note: you must first consult with your family doctor to rule out/treat any conflicting conditions like ADHD, anxiety, etc.)
*Please be advised that we only deal with the auditory conditions listed above; if your condition is not listed, then it is likely beyond the scope of our practice.
On a scale of 1 to 5, how much do any of the above conditions affect your quality of life? If you are experiencing more than one condition, rate the one that affects you the most.*

1

2

3

4

5

1 is Low, 5 is Severe
2. How long has this been going on?*
3. How did it start?*
4. Have you talked to your family/general doctor about your concerns? If so, what was the outcome?*
5. Have you seen an Ear, Nose, and Throat (ENT) specialist? If so, what was the outcome?*
6. Have you had your hearing tested?*

YesNo
7. If you have had your hearing tested, how long ago was this done?
8. If you have had your hearing tested, what recommendations or follow up was made for you?
e.g., hearing aids were recommended
9. Have you received treatment of ANY kind from a hearing health care professional (including hearing aids)? If so, how long ago did you see them/get your hearing aids?*
10. If you have tinnitus, what does it sound like?
e.g., ringing, buzzing, hissing, etc
11. Have you been bothered by sounds you hear in everyday life (that don't seem to bother other people)? If yes, please describe:
e.g., the sound of dishes clanging is so loud that it hurts my ears
12. Please tell us about any other medical/psychological/cognitive conditions that may be affecting what's going on:
e.g., depression, anxiety, ADHD, concussion, etc.
13. If you have additional details about your situation, please include it here:
Should be Empty:

Pre-Screening Questionnaire

Looking for more information?

Basic Personal Information