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Tinnitus Handicap Inventory (301090-DT)

Tinnitus Handicap Inventory (301090-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301090-DT (Rev. 11/16/16) TINNITUS HANDICAP INVENTORY Page 1 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
TINNITUS HANDICAP INVENTORY




Date: _________________________________

Instructions: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your
tinnitus. Please answer every question. Please do not skip any questions.

1. Because of your tinnitus, is it difficult for you to concentrate? Yes Sometimes No
2. Does the loudness of your tinnitus make it difficult for you to hear people? Yes Sometimes No
3. Does your tinnitus make you angry? Yes Sometimes No
4. Does your tinnitus make you feel confused? Yes Sometimes No
5. Because of your tinnitus, do you feel desperate? Yes Sometimes No
6. Do you complain a great deal about your tinnitus? Yes Sometimes No
7. Because of your tinnitus, do you have trouble falling to sleep at night? Yes Sometimes No
8. Do you feel as though you cannot escape your tinnitus? 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)?
Yes Sometimes No
10. Because of your tinnitus, do you feel frustrated? Yes Sometimes No
11. Because of your tinnitus, do you feel that you have a terrible disease? Yes Sometimes No
12. Does your tinnitus make it difficult for you to enjoy life? Yes Sometimes No
13. Does your tinnitus interfere with your job or household responsibilities? Yes Sometimes No
14. Because of your tinnitus, do you find that you are often irritable? Yes Sometimes No
15. Because of your tinnitus, is it difficult for you to read? Yes Sometimes No
16. Does your tinnitus make you upset? Yes Sometimes No
17. Do you feel that your tinnitus problem has placed stress on your
relationships with members of your family and friends?
Yes Sometimes No
18. Do you find it difficult to focus your attention away from your tinnitus and
on other things?
Yes Sometimes No
19. Do you feel that you have no control over your tinnitus? Yes Sometimes No
20. Because of your tinnitus, do you often feel tired? Yes Sometimes No
21. Because of your tinnitus, do you feel depressed? Yes Sometimes No
22. Does your tinnitus make you feel anxious? Yes Sometimes No
23. Do you feel that you can no longer cope with your tinnitus? Yes Sometimes No
24. Does your tinnitus get worse when you are under stress? Yes Sometimes No
25. Does your tinnitus make you feel insecure? Yes Sometimes No
FOR CLINICIAN USE ONLY

Total Per Column


Total Score
































































































































Newman, C.W., Jacobson, G.P., Spitzer, J.B. (1996). Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 122, 143-8.
x4 x2 x0
+ + =

Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM



To interpret the score, please refer to the Tinnitus
Handicap Severity Scale shown on the reverse side.



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter

301090-DT (Rev. 11/16/16) TINNITUS HANDICAP INVENTORY Page 2 of 2
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
TINNITUS HANDICAP INVENTORY





GRADE SCORE DESCRIPTION
1 0-16 Slight: Only heard in quiet environment, very easily masked. No interference with sleep or daily
activities.
2 18-36 Mild: Easily masked by environmental sounds and easily forgotten with activities. May occasionally
interfere with sleep but not daily activities.
3 38-56 Moderate: May be noticed, even in the presence of background or environmental noise, although
daily activities may still be performed.
4 58-76 Severe: Almost always heard, rarely, if ever, masked. Leads to disturbed sleep pattern and can
interfere with ability to carry out normal daily activities. Quiet activities affected adversely.
5 78-100 Catastrophic: Always heard, disturbed sleep patterns, difficulty with any activity.