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Tinnitus History Questionnaire

Tinnitus History Questionnaire

Please fill out this form and one of our licensed audiologists will contact you.

Name
FirstLast
Date of Birth
Email
Nature of the Tinnitus
How does the tinnitus sound?
Usual site of the tinnitus?
- Left =Right
- Left worse than Right
- Right worse than Left
- Central
Is the tinnitus constant or intermittent?
- constant
- intermittent
Does the tinnitus fluctuate in intensity?
- yes
- no
What makes your tinnitus worse?
What makes your tinnitus better?
Tinnitus History
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?
- None
- Hearing Aid
- Masker
- TRT
- Counselling
- Music Therapy
- Other - please comment below
If Other was selected above, pplease specify.
How successful did you find these treatments?

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Forms

Tinnitus History Questionnaire
Tinnitus Reaction Questionnaire (TRQ)

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