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, 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 WEEK23. 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