Welcome to our Clinic

Please complete the Tinnitus History Questionnaire below prior to your appointment.

Help is at hand…

If you have any difficulties with the forms please leave the space blank and we will help you during your visit.
You can also contact reception at admin@healthyhearing.com.au if you have any questions.

THQ

Tinnitus History Questionnaire
  • Nature of the Tinnitus

  • Tinnitus History

  • Tinnitus History Questionnaire

  • 15. Have you ever been exposed to gunfire or explosion?

    Yes
    No
    Comments/Details:
  • 16. Have you ever attended loud events e.g. music concerts or clubs?

    Yes
    No
    Comments/Details:
  • 17. Have you ever had any noisy jobs?

    Yes
    No
    Comments/Details:
  • 18. Have you ever had any noisy hobbies or home activities?

    Yes
    No
    Comments/Details:
  • 19. Have you ever had any head injuries or concussion?

    Yes
    No
    Comments/Details:
  • 20. Have you ever had any operations involving your ear or head?

    Yes
    No
    Comments/Details:
  • 22. Have you ever used solvents, thinners or alcohol based cleaners?

    Yes
    No
    Comments/Details:
  • 23. Do you have loose dentures, jaw pain or grinding and clicking sensations in the jaw?

    Yes
    No
    Comments/Details:
  • 24. Do you regularly take aspirin or dispirin?

    Yes
    No
    Comments/Details:
  • 25. Do you have any feelings of ear pressure or blockage?

    Yes
    No
    Comments/Details:
  • 26. Do you find exposure to moderately loud sounds make your tinnitus worse?

    Yes
    No
    Comments/Details:
  • General Hearing Problems

  • 28. Do you have difficulties hearing when there is background noise?

    Yes
    No
    Comments/Details:
  • 29. Do you have difficulties understanding in one-to-one conversations?

    Yes
    No
    Comments/Details:
  • 30. Do you have difficulties hearing the TV?

    Yes
    No
    Comments/Details:
  • 31. Do you have difficulties hearing on the telephone?

    Yes
    No
    Comments/Details:
  • 32. Do you have dizziness or balance problem?

    Yes
    No
    Comments/Details:
  • 33. Do you find external sounds unpleasant or uncomfortable?

    Yes
    No
    Comments/Details:
  • 34. Do you dislike certain external sounds?

    Yes
    No
    Comments/Details:
  • 35. Do you wear ear protection or ear plugs?

    Yes
    No
    Comments/Details:
  • 36. Please rank the auditory problems you experience from the most troublesome (1) to least troublesome (3)?

    Hearing Loss
    Tinnitus
    Sensitivity to Loud Sounds
  • Effect of the Tinnitus

  • 39. Does your tinnitus prevent you from getting to sleep at night?

    Yes
    No
    Comments/Details:
  • General Health

  • Compensation

  • Medical Contact Details

  • I give consent to release results to my GP/ENT