Tinnitus Handicap Inventory Form - Hearts for Hearing

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Home / Adults / Tinnitus / Tinnitus Handicap Inventory Form

Tinnitus Survey

First and Last Name(Required)

Please enter both your FIRST and LAST name.

1. Because of your tinnitus, is it difficult for you to concentrate?(Required)

Yes

Sometimes

No

2. Does the loudness of your tinnitus make it difficult for you to hear people?(Required)

Yes

Sometimes

No

3. Does your tinnitus make you angry?(Required)

Yes

Sometimes

No

4. Does your tinnitus make you feel confused?(Required)

Yes

Sometimes

No

5. Does your tinnitus make you feel desperate?(Required)

Yes

Sometimes

No

6. Do you complain a great deal about your tinnitus?(Required)

Yes

Sometimes

No

7. Because of your tinnitus, do you have trouble falling to sleep at night?(Required)

Yes

Sometimes

No

8. Do you feel as though you cannot escape your tinnitus?(Required)

Yes

Sometimes

No

9. Does your tinnitus interfere with your ability to enjoy your social activities(such as going out to dinner, to the movies)?(Required)

Yes

Sometimes

No

10. Because of your tinnitus, do you feel frustrated?(Required)

Yes

Sometimes

No

11. Because of your tinnitus, do you feel that you have a terrible disease?(Required)

Yes

Sometimes

No

12. Does your tinnitus make it difficult for you to enjoy life?(Required)

Yes

Sometimes

No

13. Does your tinnitus interfere with your job or household responsibilities?(Required)

Yes

Sometimes

No

14. Because of your tinnitus, do you find that you are often irritable?(Required)

Yes

Sometimes

No

15. Because of your tinnitus, is it difficult for you to read?(Required)

Yes

Sometimes

No

16. Does your tinnitus make you upset?(Required)

Yes

Sometimes

No

17. Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?(Required)

Yes

Sometimes

No

18. Do you find it difficult to focus your attention away from your tinnitus and on other things?(Required)

Yes

Sometimes

No

19. Do you feel that you have no control over your tinnitus?(Required)

Yes

Sometimes

No

20. Because of your tinnitus, do you often feel tired?(Required)

Yes

Sometimes

No

21. Because of your tinnitus, do you feel depressed?(Required)

Yes

Sometimes

No

22. Does your tinnitus make you feel anxious?(Required)

Yes

Sometimes

No

23. Do you feel that you can no longer cope with your tinnitus?(Required)

Yes

Sometimes

No

24. Does your tinnitus get worse when you are under stress?(Required)

Yes

Sometimes

No

25. Does your tinnitus make you feel insecure?(Required)

Yes

Sometimes

No

This field is hidden when viewing the form

Number

26. What state are you coming from?(Required)

If not in Oklahoma, are you willing/able to come to Oklahoma for an in-person consultation?

27. Do you experience seizures or have a seizure disorder?(Required)

28. If female, are you pregnant?(Required)

29. Do you experience facial nerve pain/neuralgia?(Required)

30. Do you have a pacemaker or defibrillator?(Required)

31. Do you have a cochlear implant, or other battery-operated implanted device?(Required)

If yes, which one?

32. Do you have a history of recurrent sores in your mouth (on lips, tongue, or palate)?(Required)

33. Do you have any impaired sensitivity of your tongue or tongue disorders?(Required)

34. Have you been diagnosed with Meniere’s disease?(Required)

35. Have you sought treatment for your tinnitus before?(Required)

If yes, what treatments have you tried?

Phone Number(Required)

Email(Required)

Where did you hear about us?(Required)

This appointment will have a $150 consultation fee which is not covered by insurance and is due at the time of the appointment. Are you ok with this fee and want to proceed with scheduling?(Required)

Yes

No

Would you like to still be scheduled for just a hearing test without the tinnitus consultation and fee?

Yes

No

I confirm each question was filled out to the best of my ability and agree to be contacted by a provider to hear more about treatment options available to me.(Required)

I agree

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