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Tinnitus Questionnaire (301089-DT)

Tinnitus Questionnaire (301089-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


Page 1 of 2


Patient Name:

DOB:

MR #:


Date: ___________________________________























































UWH# 301090-DT (Rev. 11/11/15) Scan to Questionnaire-Health TINNITUS QUESTIONNAIRE
University of Wisconsin Hospitals and Clinics
University of Wisconsin Medical Foundation
TINNITUS QUESTIONNAIRE

Address: ___________________________________________________________ Age: ___________________________
___________________________________________________________________ Phone: _______________________
1. I have had tinnitus in its present form for: (Circle one)
a. Less than 1 year d. Three to five years
b. One to two years e. Longer than five years
c. Two to three years

2. Prior to my present form of tinnitus I had a mild tinnitus for ____________________ years.
(number)
3. My tinnitus seems to be primarily located in: (Circle one)
a. The left ear d. Both ears but unequal
b. The right ear e. My head
c. Both ears equally

4. The severity of my tinnitus in its worst form, according to the scale below is represented by the number: (Circle
appropriate number)



1 2 3 4 5 6 7 8 9 10







5. The loudness of my tinnitus is: (Circle one)
a. Fairly constant from day to day.
b. Fluctuates widely, being very loud on some days and very mild other days.
c. Usually constant but on rare occasions will decrease markedly.
d. Usually constant but will increase markedly.

6. If my tinnitus changes from time to time, these changes are caused by: ________________________________
_________________________________________________________________________________________
7. On the scale below indicate the pitch of your tinnitus. It might help to imagine the scale as if it were a piano
keyboard: (Circle appropriate number)


1 2 3 4 5 6 7 8 9 10






8. Circle any item below that describes how your tinnitus sounds: (Circle all appropriate)
a. Hissing d. Pulsating g. Bells i. Clanging
b. Cricket-like e. Whistle h. Pounding j. Ringing
c. Steam whistle f. Ocean roar


9. My tinnitus appears worse: (Circle all appropriate)

a. When I am tired c. When I am relaxed
b. When I am tense and nervous d. After use of alcohol
Mild
Tinnitus
Moderate
Tinnitus
Extremely
Severe
Low
pitch
Middle
pitch
High
pitch

Page 2 of 2


Patient Name:

DOB:

MR #:



10. Do you smoke? Yes No
If so, how long have you been smoking? __________years
If so, how many cigarettes per day? __________________

11. Do you drink coffee? Yes No
If so, how many cups per day?____________________

12. Circle any of the following items that give you any relief from your tinnitus:

a. Listening to radio or T.V. d. Medication (___________________________)
b. Traffic sounds e. Changes in altitude
c. Sounds of running water (e.g. shower) f. Other: __________________________________

13. Have you ever received a head injury?
If so, were you knocked unconscious?
How long ago did the accident occur? __________________________years

14. Have you ever been exposed to loud sounds? Yes No
Explain: ___________________________________________________________________

15. Do you wear ear protection in the presence of loud sounds? Yes No

16. Have you ever worn a hearing aid? Yes No

17. Do you have any of the following? (Circle all appropriate)
a. High Blood Pressure c. Allergies
b. Diabetes d. Other: ________________

18. Does tinnitus cause you problems getting to sleep? Yes No

19. If you are a hearing aid user, how does the aid affect your tinnitus? _________________________________
_______________________________________________________________________________________
20. Are you taking medication? Yes No
21. What medications are you currently taking? ____________________________________________________
_______________________________________________________________________________________
22. Do you have a history of ear disease? Explain: __________________________________________________
_______________________________________________________________________________________
23. Do you have a hearing loss? Yes No Right Ear Left Ear














UWH# 301090-DT (Rev. 11/11/15) Scan to Questionnaire-Health TINNITUS QUESTIONNAIRE
University of Wisconsin Hospitals and Clinics
University of Wisconsin Medical Foundation
TINNITUS QUESTIONNAIRE

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