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Advanced Hearing Solutions
Audiology Services

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

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

"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.,
Patient

2016-03-22T12:31:10+00:00

James M.,
Patient

"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."
"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.,
Patient

2016-03-22T12:29:19+00:00

Rita H.,
Patient

"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."
"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.,
Patient

2016-03-22T12:31:54+00:00

Debra B.,
Patient

"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."
"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.,
Patient

2016-03-22T12:28:41+00:00

Roberta T.,
Patient

"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."
"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.,
Patient

2016-03-22T12:30:08+00:00

Diana M.,
Patient

"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."

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