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Patient Number: ELC00001 Date: 1/21/2021
 
The purpose of the scale is to identify the problems your tinnitus may be causing you. Select "Yes", "Sometimes", or "No" for each questions.
 Please do not skip a question (required) 
1. Because of your tinnitus, is it difficult to concentrate? Yes     Sometimes     No    
2. Does the loudness of your tinnitus make it difficult for you to hear people? Yes     Sometimes     No    
3. Does your tinnitus make you angry? Yes     Sometimes     No    
4. Does your tinnitus make you feel confused? Yes     Sometimes     No    
5. Because of your tinnitus, do you feel desperate? Yes     Sometimes     No    
6. Do you complain a great deal about your tinnitus? Yes     Sometimes     No    
7. Because of your tinnitus, do you have trouble falling to sleep at night? Yes     Sometimes     No    
8. Do you feel that you cannot escape from your tinnitus? Yes     Sometimes     No    
9. Does your tinnitus interfere with your ability to enjoy social activities (such as going out to dinner, to the movies)? Yes     Sometimes     No    
10. Because of your tinnitus, do you feel frustrated? Yes     Sometimes     No    
11. Because of your tinnitus, do you feel that you have a terrible disease? Yes     Sometimes     No    
12. Does your tinnitus make it difficult for you to enjoy life? Yes     Sometimes     No    
13. Does your tinnitus interfere with your job or household duties? Yes     Sometimes     No    
14. Because of your tinnitus, do you find that you are often irritable? Yes     Sometimes     No    
15. Because of your tinnitus, is it difficult for you to read? Yes     Sometimes     No    
16. Does your tinnitus make you upset? Yes     Sometimes     No    
17. Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends? Yes     Sometimes     No    
18. Do you find it difficult to focus your attention away from your tinnitus and on other things? Yes     Sometimes     No    
19. Do you feel that you have no control over your tinnitus? Yes     Sometimes     No    
20. Because of your tinnitus, do you often feel tired? Yes     Sometimes     No    
21. Because of your tinnitus, do you feel depressed? Yes     Sometimes     No    
22. Does your tinnitus make you feel anxious? Yes     Sometimes     No    
23. Do you feel that you can no longer cope with your tinnitus? Yes     Sometimes     No    
24. Does your tinnitus get worse when you are under stress? Yes     Sometimes     No    
25. Does your tinnitus make you feel insecure? Yes     Sometimes     No    
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