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1.
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Because of your tinnitus, is it difficult to concentrate?
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Yes
Sometimes
No
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2.
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Does the loudness of your tinnitus make it difficult for you to hear people?
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Yes
Sometimes
No
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3.
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Does your tinnitus make you angry?
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Yes
Sometimes
No
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4.
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Does your tinnitus make you feel confused?
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Yes
Sometimes
No
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5.
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Because of your tinnitus, do you feel desperate?
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Yes
Sometimes
No
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6.
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Do you complain a great deal about your tinnitus?
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Yes
Sometimes
No
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7.
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Because of your tinnitus, do you have trouble falling to sleep at night?
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Yes
Sometimes
No
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8.
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Do you feel that you cannot escape from your tinnitus?
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Yes
Sometimes
No
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9.
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Does your tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the movies)?
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Yes
Sometimes
No
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10.
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Because of your tinnitus, do you feel frustrated?
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Yes
Sometimes
No
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11.
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Because of your tinnitus, do you feel that you have a terrible disease?
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Yes
Sometimes
No
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12.
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Does your tinnitus make it difficult for you to enjoy life?
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Yes
Sometimes
No
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13.
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Does your tinnitus interfere with your job or household duties?
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Yes
Sometimes
No
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14.
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Because of your tinnitus, do you find that you are often irritable?
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Yes
Sometimes
No
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15.
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Because of your tinnitus, is it difficult for you to read?
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Yes
Sometimes
No
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16.
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Does your tinnitus make you upset?
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Yes
Sometimes
No
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17.
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Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends?
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Yes
Sometimes
No
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18.
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Do you find it difficult to focus your attention away from your tinnitus and on other things?
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Yes
Sometimes
No
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19.
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Do you feel that you have no control over your tinnitus?
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Yes
Sometimes
No
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20.
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Because of your tinnitus, do you often feel tired?
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Yes
Sometimes
No
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21.
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Because of your tinnitus, do you feel depressed?
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Yes
Sometimes
No
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22.
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Does your tinnitus make you feel anxious?
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Yes
Sometimes
No
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23.
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Do you feel that you can no longer cope with your tinnitus?
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Yes
Sometimes
No
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24.
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Does your tinnitus get worse when you are under stress?
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Yes
Sometimes
No
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25.
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Does your tinnitus make you feel insecure?
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Yes
Sometimes
No
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