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18525 W. Lake Houston Pkwy 102A Humble, TX 77346 (281) 361-4327 (281) 361-3094 www.nehoustonhearing.com
Hearing Matters
TINNITUS PATIENT SCREENING TOOL Name: ___________________________ Date: ________________________
Please circle the response that most accurately reflects your feelings about your tinnitus. ( 1=Not often, 5 = Very often)
How often do you feel frustrated by your tinnitus?
1
2
3
4
How often does your tinnitus make it difficult for you to concentrate or focus?
1
2
3
4 5
How often does your tinnitus negatively affect your sleeping habits?
1
2
3
4
5
How often does your tinnitus negatively impact your life?
1
2
3
4
5
How often does your tinnitus affect your family/social relationships?
1
2
3
4
5
If someone could help you understand your tinnitus better, would you be interested?
Yes
5
No