Audiology Questionnaires

Tinnitus Functional Index

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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...

1. What percentage of your time awake were you consciously AWARE OF your tinnitus?
Never aware - 0% 100% - Always aware


2. How STRONG or LOUD was your tinnitus?
Not at all strong or loud - 0 10 - Extremely strong or loud


3. What percentage of your time awake were you ANNOYED by your tinnitus?
None of the time - 0% 100% - All the time

Over the PAST WEEK...

4. Did you feel IN CONTROL in regard to your tinnintus?
Very much in control - 0 10 - Never in control


5. How easy was it for you to COPE with your tinnintus?
Very easy to cope - 0 10 - Impossible to cope


6. How easy was it for you to IGNORE your tinnintus?
Very easy to ignore - 0 10 - Impossible to ignore

Over the PAST WEEK...

7. Your ability to CONCENTRATE?
Did not interfere - 0 10 - Completely interfered


8. Your ability to THINK CLEARLY?
Did not interfere - 0 10 - Completely interfered


9. Your ability to FOCUS ATTENTION?
Did not interfere - 0 10 - Completely interfered

Over the PAST WEEK...

10. How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?
Never had difficulty - 0 10 - Always had difficulty


11. How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?
Never had difficulty - 0 10 - Always had difficulty


12. How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?
None of the time - 0 10 - All of the time

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

13. Your ability to HEAR CLEARLY?
Did not interfere - 0 10 - Completely interfered


14. Your ability to UNDERSTAND PEOPLE who are talking?
Did not interfere - 0 10 - Completely interfered


15. Your ability to FOLLOW CONVERSATIONS in a group or at meetings?
Did not interfere - 0 10 - Completely interfered

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

16. Your QUIET RESTING ACTIVITIES?
Did not interfere - 0 10 - Completely interfered


17. Your ability to RELAX?
Did not interfere - 0 10 - Completely interfered


18. Your ability to enjoy 'PEACE AND QUIET'?
Did not interfere - 0 10 - Completely interfered

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

19. Your enjoyment of SOCIAL ACTIVITIES?
Did not interfere - 0 10 - Completely interfered


20. Your ENJOYMENT OF LIFE?
Did not interfere - 0 10 - Completely interfered


21. Your RELATIONSHIPS with family, friends and other people?
Did not interfere - 0 10 - Completely interfered


22. How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, school work, or caring for children or others?
Never had difficulty - 0 10 - Always had difficulty

Over the PAST WEEK...

23. How ANXIOUS or WORRIED has your tinnitus made you feel?
0 10 - Completely interfered


24. How BOTHERED or UPSET have you been because of your tinnitus?
Not at all bothered or upset- 0 10 - Extremely bothered or upset


25. How DEPRESSED were you because of your tinnitus?
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’:

Most of the timeA lot of the timeFrom time to time, occasionallyNot at all

I still enjoy the things I used to enjoy:

Definitely as muchNot quite so muchOnly a littleHardly at all

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

Very definitely and quite badlyYes, but not too badlyA little, but it doesn’t worry meNot at all

I can laugh and see the funny side of things:

As much as I always couldNot quite as much nowDefinitely not so much nowNot at all

Worrying thoughts go through my mind:

A great deal of the timeA lot of the timeFrom time to time, but not too oftenOnly occasionally

I feel cheerful:

Not at allNot oftenSometimesMost of the time

I can sit at ease and feel relaxed:

DefinitelyUsuallyNot oftenNot at all

I feel as if I am slowed down:

Nearly all the timeVery oftenSometimesNot at all

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

Not at allOccasionallyQuite oftenVery often

I have lost interest in my appearance:

DefinitelyI don’t take as much care as I shouldI may not take quite as much care as I shouldI take as much care as ever

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

Very much indeedQuite a lotNot very muchNot at all

I look forward with enjoyment to things:

As much as I ever didRather less than I used toDefinitely less than I used toHardly at all

I get sudden feeling of panic:

Very often indeedQuite oftenNot very oftenNot at all

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

OftenSometimesNot oftenVery seldom

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