Tinnitus Handicap Inventory Survey

PATIENT INFORMATION

First Name:

Last Name:

Age:

Email:

Date:

TINNITUS HANDICAP INVENTORY SURVEY

INSTRUCTIONS: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your tinnitus. Please answer every question. Please do not skip any questions.

	Yes (4)	Sometimes (2)	No (0)
1. Because of your tinnitus, is it difficult for you to concentrate?
2. Does the loudness of your tinnitus make it difficult for you to hear people?
3. Does your tinnitus make you angry?
4. Does your tinnitus make you feel confused?
5. Because of your tinnitus, do you feel desperate?
6. Do you complain a great deal about your tinnitus?
7. Because of your tinnitus, do you have trouble falling to sleep at night?
8. Do you feel as though you cannot escape your tinnitus?
9. Does your tinnitus interfere with your ability to enjoy your social (such as going out to dinner, to the movies)?
10. Because of your tinnitus, do you feel frustrated?
11. Because of your tinnitus, do you feel that you have a terrible disease?
12. Does your tinnitus make it difficult for you to enjoy life?
13. Does your tinnitus interfere with your job or household responsibilities?
14. Because of your tinnitus, do you find that you are often irritable?
15. Because of your tinnitus, is it difficult for you to read?
16. Does your tinnitus make you upset?
17. Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?
18. Do you find it difficult to focus your attention away from your tinnitus and on other things?
19. Do you feel that you have no control over your tinnitus?
20. Because of your tinnitus, do you often feel tired?
21. Because of your tinnitus, do you feel depressed?
22. Does your tinnitus make you feel anxious?
23. Do you feel that you can no longer cope with your tinnitus?
24. Does your tinnitus get worse when you are under stress?
25. Does your tinnitus make you feel insecure?

0-16 Slight: Only heard in quiet environment, very easily masked. No interference with sleep or daily activities.
18-36 Mild: Easily masked by environmental sounds and easily forgotten with activities. May occasionally interfere with sleep but not daily activities.
38-56 Moderate: May be noticed, even in the presence of background or environmental noise, although daily activities may still be performed.
58-76 Severe: Almost always heard, rarely, if ever, masked. Leads to disturbed sleep pattern and can interfere with ability to carry out normal daily activities. Quiet activities affected adversely.
78-100 Catastrophic: Always heard, disturbed sleep pattems, difficulty with any activity.

Average:

Total: 0

Source: Newman, C.W., Jacobson, G.P., Spitzer, J.B. (1996). Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg, 122, 143-8. | McCombe, A., Baguely, D., Coles, R.. McKenna, L., McKinney, C. & Windle-Taylor, P. (2001). Guidelines for the grading of tinnitus severity: the results a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 999. Clin. Otolaryngol 26, 388-393. Form design copyright of Blueprint Solutions LLC.