Audiology – Tinnitus Review

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 enter your Hospital Number exactly as it appears on your appointment letter (required)

Surname (required)

Your personal contact Email address (required)

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 - 010 - 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 - 010 - Never in control

5. How easy was it for you to COPE with your tinnintus?
Very easy to cope - 010 - Impossible to cope

6. How easy was it for you to IGNORE your tinnintus?
Very easy to ignore - 010 - Impossible to ignore

Over the PAST WEEK...

7. Your ability to CONCENTRATE?
Did not interfere - 010 - Completely interfered

8. Your ability to THINK CLEARLY?
Did not interfere - 010 - Completely interfered

9. Your ability to FOCUS ATTENTION?
Did not interfere - 010 - Completely interfered

Over the PAST WEEK...

10. How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?
Never had difficulty - 010 - Always had difficulty

11. How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?
Never had difficulty - 010 - 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 - 010 - All of the time

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

13. Your ability to HEAR CLEARLY?
Did not interfere - 010 - Completely interfered

14. Your ability to UNDERSTAND PEOPLE who are talking?
Did not interfere - 010 - Completely interfered

15. Your ability to FOLLOW CONVERSATIONS in a group or at meetings?
Did not interfere - 010 - Completely interfered

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

16. Your QUIET RESTING ACTIVITIES?
Did not interfere - 010 - Completely interfered

17. Your ability to RELAX?
Did not interfere - 010 - Completely interfered

18. Your ability to enjoy 'PEACE AND QUIET'?
Did not interfere - 010 - Completely interfered

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

19. Your enjoyment of SOCIAL ACTIVITIES?
Did not interfere - 010 - Completely interfered

20. Your ENJOYMENT OF LIFE?
Did not interfere - 010 - Completely interfered

21. Your RELATIONSHIPS with family, friends and other people?
Did not interfere - 010 - 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 - 010 - Always had difficulty

Over the PAST WEEK...

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

24. How BOTHERED or UPSET have you been because of your tinnitus?
Not at all bothered or upset- 010 - Extremely bothered or upset

25. How DEPRESSED were you because of your tinnitus?
Not at all depressed - 010 - Extremely depressed

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

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