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Enrollment Criteria for Music Therapy Trial
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Do you own an iPhone iTouch or iPad?
iPhone
iTouch
iPad
What best describes your tinnitus?
Pulsing
Not Pulsing
Clear selection
Describe the character of the sound futher:
Beeping, tone, whistling, ringing, whining, humming,
hissing, buzzing, whooshing sound
crickets, tree frogs, locusts, other
Clear selection
Where do you hear your tinnitus?
Both ears
Mostly left ear
Mostly right ear
Diffusely in the head
Clear selection
How long have you suffered from tinnitus?
Less than 12 months
Between 1-5 years
More than five years
Clear selection
How prevalent is your tinnitus?
Several hours a week
Several hours a day
Nearly continuous
Clear selection
How severe is your tinnitus?
Minor
Moderate
Severe
Clear selection
Do you have a hearing impairment?
Little
Moderate
A Lot
Clear selection
How many hours per day do you listen to music?
Less than 1 hour
1-2 hours
More than 2
Clear selection
How do you listen to music? Mark all that apply.
Radio, CD
Music stored in iPhone or similar device
Internet streaming music,
Which of the following devices do you use? Mark all that apply.
A loudspeaker
Headphones Earbuds
Anything else that you would like to tell us about your tinnitus?
Your answer
Email
*
Your answer
Zip Code
*
Your answer
Age
*
Your answer
Gender
*
Your answer
Name
*
Your answer
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