Tinnitus Functional Index
This is a standard  form as used by health professionals to measure your tinnitus and to monitor change over time.
Sign in to Google to save your progress. Learn more
1. Over the PAST WEEK ... *
How STRONG or LOUD was your tinnitus?  0=none  10=loud
2. Over the PAST WEEK ...  What percentage of your time awake *
were you consciously AWARE OF your tinnitus?   0=0%  10=100% or all the time
3. Over the PAST WEEK ...  What percentage of your time awake *
were you consciously ANNOYED by your tinnitus?  0=0% 10=100%
4. Over the PAST WEEK ... Did you feel IN CONTROL *
 in regard to your tinnitus?   0=total control   10=never in control
5. Over the PAST WEEK ... How easy was it for you *
to COPE with your tinnitus?  0=very easy   10=impossible
6. Over the PAST WEEK ... How easy was it for you *
to IGNORE your tinnitus?  0=easy    10=impossible to ignore
7 Over the PAST WEEK ... Your ability to *
CONCENTRATE?  0=no interference 10=intense interference
8 Over the PAST WEEK ... Your ability to *
THINK CLEARLY? 0=no interference   10=intense interference
9. Over the PAST WEEK ... Your ability to FOCUS ATTENTION *
on other things besides your tinnitus?  0=no interference  10=total interference
10 Over the PAST WEEK ... How often did your tinnitus make it *
difficult to FALL ASLEEP or STAY ASLEEP?  0=no difficulty    10=always difficult
11 Over the PAST WEEK ...How often did your tinnitus cause you   *
difficulty in getting AS MUCH SLEEP as you needed? 0=no difficulty   10=always difficult
12. Over the PAST WEEK ... ...How much of the time did  your tinnitus keep you from SLEEPING as *
 DEEPLY or as PEACEFULLY as you would have liked? 0=none    10=all of the time
13 Over the PAST WEEK .... how much has  your tinnitus interfered with...... *
Your ability to HEAR CLEARLY? 0=never   10=total interference
14 Over the PAST WEEK .... how much has  your tinnitus interfered with Your ability to *
UNDERSTAND PEOPLE who are talking?  0=no interference   10=total interference
15 Over the PAST WEEK .... how much has  your tinnitus interfered with Your ability to *
FOLLOW CONVERSATIONS in a group or at meetings?  0=no interference   10=total interference
16 Over the PAST WEEK .... how much has  your tinnitus interfered with your *
QUIET RESTING ACTIVITIES?  0=no interference   10=total interference
17 Over the PAST WEEK .... how much has  your tinnitus interfered with *
Your ability to RELAX?  0= no interference  10=total interference
18. Over the PAST WEEK .... how much has  your tinnitus interfered with your *
ability to enjoy PEACE AND QUIET?  0=no interference   10=total interference
19 Over the PAST WEEK .... how much has  your tinnitus interfered with your *
enjoyment of SOCIAL ACTIVITIES? 0=no interference    10=total interference
20 Over the PAST WEEK .... how much has  your tinnitus interfered with *
Your ENJOYMENT OF LIFE? 0=no interference    10=total interference
21 Over the PAST WEEK .... how much has  your tinnitus interfered with your *
RELATIONSHIPS with family, friends and other people? 0=no interference    10=total interference
22. Over the PAST WEEK ..  How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER *
TASKS, such as home maintenance, school work, or caring for children or others? 0=no difficulty  10=always difficult
23 Over the PAST WEEK ....How ANXIOUS or WORRIED *
has your tinnitus made you feel?    0=no anxiety    10=extreme anxiety
24 Over the PAST WEEK ....How BOTHERED or UPSET *
have you been because of your tinnitus?  0=not bothered  10=extremely upset
25 Over the PAST WEEK ....How DEPRESSED *
were you because of your tinnitus? 0=no depression   10=very depressed
Email address please. *
Thank you for completing this index.  You can enter comments below or email me at Norman@Tinnix.org
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Priebatsch.