TINNITUS FUNCTIONAL INDEX

Today's Date*

(Day / Month / Year)

Your Name*

Your Email Address*

Country

Phone Number

Your Postcode*

PRIVACY POLICY: We use a medical-grade and HIPPA-compliant data security system for data transmission and storage. We will not share your data with any other parties. We could use the data in a pooled form for research purposes, but not in a way that could publicly identify you in any form. We also need to use the data to contact you with your results and to answer any further questions you might have. CONSENT: I give my consent for Tinnitus Telecare to receive details of my name, age, addresses, and answers to the Tinnitus Functional Index questionnaire. I give my permission to be contacted by email or phone and request that the information I provide be stored securely. I consent to Tinnitus Telecare’s use of my tinnitus data for quality control, marketing, and research purposes. Please choose one of the consent options below:*

TINNITUS QUESTIONNAIRE

Please read each question below carefully. To answer a question, select ONE of the numbers that are listed for that question.

Over the past week, what percentage of your time awake were you consciously AWARE OF your tinnitus?*

2. Over the past week, how STRONG or LOUD was your tinnitus?*

3. Over the past week, what percentage of your time awake were you ANNOYED by your tinnitus?*

4. Over the past week, did you feel IN CONTROL in regard to your tinnitus?*

5. Over the past week, how easy was it for you to COPE with your tinnitus?*

6. Over the past week, how easy was it for you to IGNORE your tinnitus?*

7. Over the past week, how much did your tinnitus interfere with your ability to CONCENTRATE?*

8. Over the past week, how much did your tinnitus interfere with your ability to THINK CLEARLY? *

9. Over the past week, how much did your tinnitus interfere with your ability to FOCUS ATTENTION on other things besides your tinnitus? *

10. Over the past week, how often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP? *

11. Over the past week, how often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?*

12. Over the past week, how much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?*

13. Over the past week, how much has your how much has your tinnitus interfered with your ability to HEAR CLEARLY? *

14. Over the past week, how much has your how much has your tinnitus interfered with your ability to UNDERSTAND PEOPLE who are talking? *

15. Over the past week, how much has your tinnitus interfered with your ability to FOLLOW CONVERSATIONS in a group or at meetings? *

16. Over the past week, how much has your tinnitus interfered with your QUIET RESTING ACTIVITIES? *

17. Over the past week, how much has your tinnitus interfered with your ability to RELAX? *

18. Over the past week, how much has your tinnitus interfered with your ability to enjoy 'PEACE AND QUIET'? *

19. Over the past week, how much has your tinnitus interfered with your enjoyment of SOCIAL ACTIVITIES? *

20. Over the past week, how much has your tinnitus interfered with your ENJOYMENT OF LIFE? *

21. Over the past week, how much has your tinnitus interfered with your RELATIONSHIPS with family, friends and other people? *

22. Over the past week, how often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, schoolwork, or caring for children or others?*

23. Over the past week, how ANXIOUS or WORRIED has your tinnitus made you feel?*

24. Over the past week, how BOTHERED or UPSET have you been because of your tinnitus? *

25. Over the past week, how DEPRESSED were you because of your tinnitus?*

Over the PAST WEEK, how much has your how much has your tinnitus interfered with...
13. Your ability to HEAR CLEARLY?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

14. Your ability to UNDERSTAND PEOPLE who are talking?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         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 10         Completely interfered

Over the PAST WEEK, how much has your tinnitus interfered with...

16. Your QUIET RESTING ACTIVITIES?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

17. Your ability to RELAX?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

18. Your ability to enjoy “PEACE AND QUIET”?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

Over the PAST WEEK, how much has your tinnitus interfered with...
19. Your enjoyment of SOCIAL ACTIVITIES?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

20. Your ENJOYMENT OF LIFE?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

21. Your RELATIONSHIPS with family, friends and other people?
Did not interfere        0 1 2 3 4 5 6 7 8 9 10         Completely interfered

22. How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, schoolwork, or caring for children or others?
Never had difficulty         0 1 2 3 4 5 6 7 8 9 10         Always had difficulty

Over the PAST WEEK
23. How ANXIOUS or WORRIED has your tinnitus made you feel?
Not at all anxious or worried        0 1 2 3 4 5 6 7 8 9 10         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 10         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 10         Extremely depressed 16. Your QUIET RESTING ACTIVITIES?Did not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interfered17. Your ability to RELAX?Did not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interfered18. Your ability to enjoy “PEACE AND QUIET”?Did not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferedOver the PAST WEEK, how much has your tinnitus interfered with...19. Your enjoyment of SOCIAL ACTIVITIES?Did not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interfered20. Your ENJOYMENT OF LIFE?Did not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interfere