Tinnitus & Hearing Survey| Hearing Partners of South Florida

Tinnitus & Hearing Survey

PATIENT INFORMATION

Name:

Email:

Date:

	No, not a problem	Yes, a small problem	Yes, a moderate problem	Yes, a big problem	Yes, a very big problem

A. Tinnitus

B. Hearing

C. Sound Tolerance

Over the last week, sounds were too loud or uncomfortable for me when they seemed normal to others around me

0 0

1 1

2 2

3 3

4 4

If you responded 1, 2, 3, or 4 to the statement above:

Please list two examples of sounds that are too loud or uncomfortable for you, but seem normal to others:

*If sounds are too loud for you while wearing hearing aids, please tell your audiologist.

Welcome to Hearing Partners of South Florida! We are an independently owned, full service audiology practice focused on providing the highest quality of hearing care to each of our patients.

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Delray Beach Office

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Monday to Friday: 9am – 5pm

Boynton Beach Office

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Monday to Friday: 9am – 5pm

Jupiter Office

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Monday to Friday: 9am – 5pm

Over the last week, tinnitus kept me from sleeping.	0 0	1 1	2 2	3 3	4 4
Over the last week, tinnitus kept me from concentrating on reading.	0 0	1 1	2 2	3 3	4 4
Over the last week, tinnitus kept me from relaxing.	0 0	1 1	2 2	3 3	4 4
Over the last week, I couldn't get my mind off of my tinnitus.	0 0	1 1	2 2	3 3	4 4
Total of each column	0	0	0	0	0
					Grand Total 0

Over the last week, I couldn't understand what others were saying in noisy or crowded places.	0 0	1 1	2 2	3 3	4 4
Over the last week, I couldn't understand what people were saying on TV or in movies.	0 0	1 1	2 2	3 3	4 4
Over the last week, I couldn't understand people with soft voices.	0 0	1 1	2 2	3 3	4 4
Over the last week, I couldn't understand what was being said in group conversations.	0 0	1 1	2 2	3 3	4 4
Total of each column	0	0	0	0	0
					Grand Total 0