New Client 5-Minute Application
Thank you for contacting Dr. Ben Thompson, Au.D. Please complete the quick application to see if you are a good fit for tinnitus therapy. Our intention is to create an individualized management plan designed to significantly improve your life with tinnitus.

We strongly encourage that all of our clients obtain a hearing test and see an otologist or Ear, Nose, Throat physician prior to our first session. It is important to determine whether your tinnitus is related to a treatable condition; therefore, we strongly recommend that you have a physical examination by a physician. In addition, because of the psychological impact of tinnitus we may recommend a consultation with a behavioral health specialist.

During your initial appointment, you will be educated about current tinnitus management theories, as well as treatment options, including potential advantages and limitations. It is important to understand that most tinnitus management programs are not designed to cure tinnitus. Instead, you will learn techniques to make significant improvement towards the impact tinnitus has on your quality of life and your associated stress, which often have a positive effect on the loudness of your tinnitus. Please be aware that your success in any tinnitus program depends on your commitment and participation.

Please email your most recent hearing test, doctor reports, or other relevant information to:
ben@puretinnitus.com
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Email *
What are you hoping to achieve during your private session with Dr. Ben? *
Before we have an online tinnitus video session, please click the boxes below to agree. *
Required
"Now let's get some basic contact information." - Dr. Ben
Full Name *
Date of Birth *
Where do you live? *
Phone number (include country code)
What is your current or most recent job/occupation? If unemployed, is your unemployment due to tinnitus?
How did you find us?
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"You're almost half way finished. Time to share specifics about your tinnitus." - Dr. Ben
When did you first experience tinnitus? *
Briefly describe what you were doing when the tinnitus first became apparent to you?
Were you experiencing any kind of emotional trauma at the time when you first noticed your tinnitus? If so, explain.
What do you think is the cause of your tinnitus?
Where is your tinnitus primarily located? *
Using the scale below indicate the loudness of your tinnitus at its worst: *
Mild
Severe
Using the scale below indicate the pitch of your tinnitus: *
Low pitch
High pitch
The loudness of your tinnitus is:
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Do you feel that emotional or physical stress worsens the tinnitus?
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Do you currently wear a hearing aid? *
Does your tinnitus feel worse: *
Required
Check all items that describe the sound of your tinnitus: *
Required
To what degree are you bothered or annoyed by your tinnitus? *
Mild
Severe
When are you aware of your tinnitus?
What percentage (%) of the time are you bothered by your tinnitus?
Is there a time of day when your tinnitus is most troublesome to you?
Do you consider yourself to be a tense person?
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How does your tinnitus interfere with any of the following activities? Sleep, concentration, work, family, religious, social/recreation, exercise, etc.
Do you have a hearing loss? *
What is more of a problem for you, hearing difficulty or your tinnitus?
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Have you been exposed to loud noise (military, work, hobbies)? If so, what noise and for how much time?
If you use a hearing aid, how does it affect your tinnitus?
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Are you adversely affected by loud sounds? If yes, please explain
How would your life be different if you didn't have tinnitus? *
Have you discussed your tinnitus with friends or family members? What was their reaction?
Do you live alone?
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"Almost done! Now please tell me about your Treatment History." - Dr. Ben
Please list all evaluations and/or treatments you have had for tinnitus, including psychiatry, psychology, MRI scan, etc. Please include any relevant details (name of doctor, month/year seen, result):
Please list any surgeries you have had (potentially related to your current symptom of tinnitus):
Please list all medications you currently take for tinnitus. Does it help yes/no?
What other medications have you tried for tinnitus relief? Does it help yes/no?
Please list all other medications you currently take:
Please indicate which treatment(s) you have tried for your tinnitus:
Which of the following treatments gave you some relief?
Please check all items that are applicable to you:
Do you have a legal action or lawsuit related to your tinnitus? *
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