Audiology Questionnaires

Dear Patient,

Thank you for choosing to complete the following questionnaire by visiting or scanning QR code from your appointment letter.  The questionnaire is to find out more information before you attend your appointment. This must be submitted at least 5 days before your appointment takes place.

Please make sure you have entered your own personal email address correctly as we will reply to confirm we have received your form and you will also receive a copy of the submitted form via email. If we have any questions regarding your response we will also get in touch with you.

As part of our compliance with Data Protection and the General Data Protection Regulations any data you share with us will be processed according to Data Protection legislations and will only be used for service improvement.  Your data will be joined to become part of your Health record and will be kept for 2 years before being removed.

    Tinnitus Functional Index

    Please read each question carefully. To answer a question, slide the slider to as close to the percentage you feel answers the question.

    Over the PAST WEEK...


    Never aware - 0% 100% - Always aware



    Not at all strong or loud - 0 10 - Extremely strong or loud



    None of the time - 0% 100% - All the time

    Over the PAST WEEK...


    Very much in control - 0 10 - Never in control



    Very easy to cope - 0 10 - Impossible to cope



    Very easy to ignore - 0 10 - Impossible to ignore

    Over the PAST WEEK...


    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered

    Over the PAST WEEK...


    Never had difficulty - 0 10 - Always had difficulty



    Never had difficulty - 0 10 - Always had difficulty



    None of the time - 0 10 - All of the time

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


    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered

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


    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered

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


    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered



    Did not interfere - 0 10 - Completely interfered



    Never had difficulty - 0 10 - Always had difficulty

    Over the PAST WEEK...


    0 10 - Completely interfered



    Not at all bothered or upset- 0 10 - Extremely bothered or upset



    Not at all depressed - 0 10 - Extremely depressed

    Anxiety and Depression

    This questionnaire is designed to help us know how you feel.  Emotions play an important part in most illnesses, if we know about these feelings we can help you more.

    Please select the reply which comes closest to how you have been feeling over the past week (your immediate reaction to each statement will probably be more accurate than a long thought-out response).

    I feel tense or ‘wound up’:

    I still enjoy the things I used to enjoy:

    I get a sort of frightened feeling as if something awful is about to happen:

    I can laugh and see the funny side of things:

    Worrying thoughts go through my mind:

    I feel cheerful:

    I can sit at ease and feel relaxed:

    I feel as if I am slowed down:

    I get a sort of frightened feeling like ‘butterflies’ in the stomach:

    I have lost interest in my appearance:

    I feel restless as if I have to be on the move:

    I look forward with enjoyment to things:

    I get sudden feeling of panic:

    I can still enjoy a good book, the radio or a TV programme:

    Please tick this box if you accept these terms and conditions giving your consent regarding your responses submitted from this form.