INSTRUCTIONS: Please CHECK the correct response:
(On a scale from 0=None to 10=Extreme) 1. Rate the loudness of your tinnitus:0 1 2 3 4 5 6 7 8 9 10 2. Rate the pitch of your tinnitus: 0 1 2 3 4 5 6 7 8 9 10
INSTRUCTIONS: (Please read carefully): The purpose of the scale is to identify difficulties that you may be experiencing because of your tinnitus. Please check off "YES," "SOMETIMES," or "NO" to each item. Please do not skip any questions.
YES
SOMETIMES
NO
F1. Because of your tinnitus, is it difficult for you to concentrate?
F2. Does the loudness of your tinnitus make it difficult for you to hear?
E3. Does your tinnitus make you angry?
F4. Does your tinnitus make you feel confused?
C5. Because of your tinnitus, do you feel desperate?
E6. Do you complain a great deal about you tinnitus?
F7. Because of your tinnitus, do you have trouble falling to sleep at night?
C8. Do you feel as though you cannot escape your tinnitus?
F9. Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies, etc)?
E10. Because of your tinnitus, do you feel frustrated?
C11. Because of your tinnitus, do you feel that you have a terrible disease?
F12. Does you tinnitus make it difficult to enjoy life?
F13. Does your tinnitus interfere with your job or household responsibilities?
E14. Because of your tinnitus do you find that you are often irritable?
F15. Because of you tinnitus, is it difficult for you to read?
E16. Does you tinnitus make you upset?
E17. Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?
F18. Do you find it difficult to focus your attention away from your tinnitus and on other things?
C19. Do you feel you have no control over your tinnitus?
F20. Because of your tinnitus, do you often feel tired?
E21. Because of your tinnitus, do you feel depressed?
E22. Does your tinnitus make you feel anxious?
C23. Do you feel you can no longer cope with your tinnitus?
F24. Does your tinnitus get worse when you are under stress?