TINNITUS SCREENING QUESTIONAIRE Once submitted, a copy of this questionnaire will be sent to our office. Your Name* Your Email* Phone* Date of Birth* Do you have Tinnitus? YesNo How frequent do you experience Tinnitus? ConstantlyIntermittently Where is the location of your Tinnitus? Right EarLeft EarBoth EarsHead What does your Tinnitus sound like? High Pitched RingBuzzBoth EarsHeart Beat/PulsatileOther Do you experience dizziness with your Tinnitus? YesNo How long have you had Tinnitus? Less than 3 months3 months or longer How much of a problem is your Tinnitus? No ProblemSmall ProblemModerate ProblemBig Problem Does Tinnitus affect your sleep? NeverRarelySome of the timeOftenAlways Do you have a hearing problem? YesNo Do you find everyday sounds uncomfortable? YesNo Please leave this field empty. Were you referred to our ENT Practice/Audiology Department? If yes, by whom? If no, how did you find out about us? Tinnitus Treatment Tinnitus Questionnaire Tinnitus Handicap Inventory Tinnitus FAQ Why Wait? You don’t have to live with ringing in your ears. CALL US TODAY Why Wait? You don’t have to live with ringing in your ears. CALL US TODAY
