1. I have had Tinnitus in its present form for:

(Please circle appropriate letter)

A.      Less than a year

B.      One to two years

C.      Two to three years

D.      Three to five years

E.      Longer than five years

2. Prior to my present form of Tinnitus I had a mild Tinnitus for ____________months/years

3. My Tinnitus seems to be primarily located in:

A.      The left ear

B.      The right ear

C.      Both ear equally

D.      Both ear but unequal

E.      My head

4. The severity of my Tinnitus in its worse form, according to the scale below, is represented by the number:

1     2     3     4     5     6     7     8     9     10

mild                     moderate                     extremely severe

5. The loudness of my Tinnitus is:

A.      Fairly constant from day to day.

B.      Fluctuates widely being very loud some days and very mild other days.

C.      Usually constant but on rare occasions will decrease markedly.

6. On the scale below indicate the pitch of your Tinnitus. It might help to imagine the scale as if it were a piano keyboard.

1     2     3     4     5     6     7     8     9     10

low pitch                middle pitch             high pitch

7. Circle any items below which describe how your Tinnitus sounds:

A.      Hissing

B.      Cricket-like

C.      Pounding

D.      Pulsating

E.      Whistle

F.      Ringing

G.     Steam whistle

H.      Bells

I.         Clanging

J.       Ocean roaring

8. My Tinnitus appears worse:  

A.      When I am tired

B.      When I am tense/nervous

C.      When I am relaxed

D.      After use of alcohol

9. Do you smoke (circle one)   YES     or     NO

1)       If so, for how long have being a smoker? _______years

2)       If so, how many cigarettes per day? _______

10. Do you drink coffee (circle one)   YES     or      NO

1)       If so, how many cups per day?_______

11. Circle any of the following items which give you any relief from your Tinnitus:

A.      Listening to radio/T.V.

B.      Traffic sounds

C.      Sounds of running water

D.      Medication ____________________

E.      Changes in altitude

F.      Other __________________________________________

12. Have you ever received a head injury?   YES     or     NO

1)       If so, were you knocked unconscious?   YES     or     NO

2)       How long ago was the incident? ________years

13. Have you been exposed to loud sounds?   YES     or     NO

1)       If yes, explain briefly_______________________________________________________________________

14. Are you presently working in or exposed to loud noise?   YES     or     NO

15. Do you wear ear protection in noisy places?   YES     or     NO