Tinnitus Together Sign-Up

Tinnitus Together Sign-Up
Name

First NameLast Name
Date of Birth

MonthDayYear
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Address

Street Address

Street Address Line 2

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Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
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Your Tinnitus Experience

For the following survey questions, choose on the scale:

1. Not a problem

2. Yes, a small problem

3. Yes, a moderate problem

4. Yes, a big problem

5. Yes, a very big problem.
Tinnitus - Over the last week, tinnitus kept me from sleeping
Tinnitus - Over the last week, tinnitus kept me from relaxing.
Tinnitus - Over the last week, I couldn’t get my mind off of my tinnitus.
Hearing - Over the last week, I couldn’t understand what others were saying in noisy or crowded places.
Hearing - Over the last week, I couldn’t understand what people were saying on TV or in movies.
Hearing - Over the last week, I couldn’t understand what was being said in group conversations.
Sound Tolerance - Over the last week, sounds were too loud or uncomfortable for me when they seemed normal to others around me.
How did you hear about us?
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