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?

    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.