Tinnitus Functional Index

Please read each question below carefully.

To answer a question, select one of the numbers listed that best matches your situation.

Each field and question must be completed.

Customer Details

Please enter your name, date of birth and whether you'd like a copy of your answers and result.

Patient Email (not Clinician email)

Patient Date of Birth

I | Over the PAST WEEK...

What percentage of your time awake were you consciously AWARE OF your tinnitus?

0% (never aware)

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% (always aware)

How STRONG or LOUD was your tinnitus?

0 (not at all strong or loud)

10 (extremely strong or loud)

What percentage of your time awake were you ANNOYED by your tinnitus?

0% (none of the time)

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% (all of the time)

SC | Over the PAST WEEK...

Did you feel IN CONTROL in regard to your tinnitus?

0 (very much in control)

10 (never in control)

How easy was it for you to COPE with your tinnitus?

0 (very easy to cope)

10 (impossible to cope)

How easy was it for you to IGNORE your tinnitus?

0 (very easy to ignore)

10 (impossible to ignore)

C | Over the PAST WEEK, how much did your tinnitus interfere with...

Your ability to CONCENTRATE?

0 (did not interfere)

10 (completely interfered)

Your ability to THINK CLEARLY?

0 (did not interfere)

10 (completely interfered)

Your ability to FOCUS ATTENTION on other things besides your tinnitus?

0 (did not interfere)

10 (completely interfered)

SL | Over the PAST WEEK...

How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?

0 (never had difficulty)

10 (always had difficulty)

How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?

0 (never had difficulty)

10 (always had difficulty)

How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?

0 (none of the time)

10 (all of the time)

A | Over the PAST WEEK, how much has your tinnitus interfered with...

Your ability to HEAR CLEARLY?

0 (did not interfere)

10 (completely interfered)

Your ability to UNDERSTAND PEOPLE who are talking?

0 (did not interfere)

10 (completely interfered)

Your ability to FOLLOW CONVERSATIONS in a group or at meetings?

0 (did not interfere)

10 (completely interfered)

R | Over the PAST WEEK, how much has your tinnitus interfered with...

Your QUIET RESTING ACTIVITIES?

0 (did not interfere)

10 (completely interfered)

Your ability to RELAX?

0 (did not interfere)

10 (completely interfered)

Your ability to enjoy “PEACE AND QUIET”?

0 (did not interfere)

10 (completely interfered)

Q | Over the PAST WEEK, how much has your tinnitus interfered with...

Your enjoyment of SOCIAL ACTIVITIES?

0 (did not interfere)

10 (completely interfered)

Your ENJOYMENT OF LIFE?

0 (did not interfere)

10 (completely interfered)

Your RELATIONSHIPS with family, friends and other people?

0 (did not interfere)

10 (completely interfered)

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 (never had difficulty)

10 (always had difficulty)

E | Over the PAST WEEK...

How ANXIOUS or WORRIED has your tinnitus made you feel?

0 (not at all anxious or worried)

10 (extremely anxious or worried)

How BOTHERED or UPSET have you been because of your tinnitus?

0 (not at all bothered or upset)

10 (extremely bothered or upset)

How DEPRESSED were you because of your tinnitus?

0 (not at all depressed)

10 (extremely depressed)