Tinnitus History Questionnaire

Name *

Date of Birth *

Phone # *

Email *

What location are you visiting? *
AmherstWilliamsvilleOrchard ParkTonawanda

Nature of the Tinnitus (How does the tinnitus sound?) *

Usual site of the tinnitus? *
Left=RightLeft worse than RightRight worse than LeftCentral

Is the tinnitus constant or intermittent? *

Does the tinnitus fluctuate in intensity? *

What makes your tinnitus worse? *

What makes your tinnitus better? *

How did you hear about us?*
TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther

When did you first become aware of your tinnitus? *

When did your tinnitus first become disturbing? *

Under what circumstances did the tinnitus start? *

What do you consider to have started the tinnitus? *

Who have you consulted about your tinnitus? *

What have previous professionals said your tinnitus is due to? *

What treatments have you tried for your tinnitus? *
NoneHearing AidMaskerTRTCounsellingMusic TherapyOther

How successful did you find these treatments? *

Have you ever been exposed to gunfire or explosion? *
YesNo

Details/Comments

Have you ever attended loud events e.g. music concerts or clubs? *
YesNo

Details/Comments

Have you ever had any noisy jobs? *
YesNo

Details/Comments

Have you ever had any noisy hobbies or home activities? *
YesNo

Details/Comments

Have you ever had any head injuries or concussion? *
YesNo

Details/Comments

Have you ever had any operations involving your ear or head? *
YesNo

Details/Comments

Have you ever taken any of the following medications? (Quinine, Quindidine, Streptomycin, Kantamycin, Dihydrostreptomycin, Neomycin) *
YesNo

Details/Comments

Have you ever used solvents, thinners or alcohol based cleaners? *
YesNo

Details/Comments

Do you have loose dentures, jaw pain or grinding and clicking sensations in the jaw? *
YesNo

Details/Comments

Do you regularly take aspirin or dispirin? *
YesNo

Details/Comments

Do you ave any feelings of ear pressure or blockage? *
YesNo

Details/Comments

Do you find exposure to moderately loud sounds make your tinnitus worse? *

What is your current occupation? *

Do you have any difficulties hearing when there is background noise? *
YesNo

Details/Comments

Do you have difficulties understanding in one-to-one conversations? *
YesNo

Details/Comments

Do you have difficulties hearing the TV? *
YesNo

Details/Comments

Do you have difficulties hearing on the telephone? *
YesNo

Details/Comments

Do you have any dizziness or balance problems? *
YesNo

Details/Comments

Do you find external sounds unpleasant or uncomfortable? *
YesNo

Details/Comments

Do you dislike certain external sounds? *
YesNo

Details/Comments

Do you wear ear protection/ ear plugs? *
YesNo

Details/Comments

What auditory problems do you experience? *
Hearing LossTinnitusSensitivity to Loud Sounds

Over the past week, what percentage of the time you were awake were you aware of your tinnitus (e.g. 100% aware all the time, 25% aware ¼ or the time)? *

What percentage of the time was it disturbing? *

Does your tinnitus prevent you from getting to sleep at night? Y/N *

How many times per night did you awake in the last week? *

How has tinnitus affected your work life? *

How has tinnitus affected your home life? *

How has tinnitus affected your social activities? *

What is your general health like? *

Are you taking any medications? (If yes, please specify) *

Are you currently pursuing any form of compensation, sickness benefit, DVA, motor vehicle accident claim or any other legal action in relation to your tinnitus? *

Name and Address of GP: *

Name and Address of ENT: *

I give consent to release results to my GP/ENT: *
YesNo

Is there anything else you would like to add that might be relevant to understanding what caused your tinnitus? *