Audiology Services


Once submitted, a copy of this questionnaire will be sent to our office.

    Your Name*

    Your Email*


    Date of Birth*

    Do you have Tinnitus?

    How frequent do you experience Tinnitus?

    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?

    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?

    Do you find everyday sounds uncomfortable?

    Were you referred to our ENT Practice/Audiology Department? If yes, by whom? If no, how did you find out about us?

    "This was the first time my tinnitus was really addressed. Part of that is due to the technology available now, but also the insight and encouragement offered by Jeannie. My tinnitus, which used to be very disturbing and anxiety producing, is now quite manageable, and does not disrupt my life at all."

    Diana M.,

    "It has been a journey to regain my hearing, reduce sound sensitivity and tinnitus control. Dr. Karlovitz expertly prescribed hearing aids to address all three of my issues. I’m now at 90% hearing correction and am adjusting to the new sounds I hear. I’ve regained my hearing world and that’s a blessing."

    Debra B.,

    "I learned so much about tinnitus. How to adjust to the problem, how to accept it for what it is, how to adapt my mindset to be able to push the tinnitus to the background. While it is still there, my reaction to it has changed. It is no longer such a bothersome burden. It has eased as a major problem in my life. It has been a wonderful experience. I enjoyed Jeannie’s open and highly professional approach."

    James M.,

    "One summer day I was feeling very depressed. I could not get rid of the ringing in my ears. After several sessions and exercises with Dr. Jeannie, my brain began to see the light of hope and ray of happiness. Dr. Jeannie is an angel of mercy who restored my bubbly personality, and sent me on a road of success."

    Rita H.,

    "I’ve had tinnitus for over twenty years, and it was exciting to find out there was a way to deal with it. With treatment the intensity of the tinnitus is less and I’m less aware of it. Didn’t feel rushed, liked the one to one relationship."

    Roberta T.,

    Why Wait? You don’t have to live with ringing in your ears.

    Why Wait? You don’t have to live with ringing in your ears.