| YES
(4 POINTS) |
SOMETIMES
(2 POINTS) |
NO
(0 POINTS) |
||
| 1 | Because of your tinnitus is it difficult for you to concentrate? | _ | _ | _ |
| 2 | Does the loudness of your tinnitus make it difficult for you to hear people? | _ | _ | _ |
| 3 | Does your tinnitus make you angry? | _ | _ | _ |
| 4 | Does your tinnitus make you confused? | _ | _ | _ |
| 5 | Because of your tinnitus, are you desperate? | _ | _ | _ |
| 6 | Do you complain to others about your tinnitus? | _ | _ | _ |
| 7 | Because of your tinnitus do you have trouble falling asleep at night? | _ | _ | _ |
| 8 | Do you feel as though you cannot escape from your tinnitus? | _ | _ | _ |
| 9 | Does your tinnitus interfere with your ability to enjoy social activities? | _ | _ | _ |
| 10 | Because of your tinnitus do you feel frustrated? | _ | _ | _ |
| 11 | Because of your tinnitus do you feel that you have a terrible disease? | _ | _ | _ |
| 12 | Does your tinnitus make it difficult to enjoy life? | _ | _ | _ |
| 13 | Does your tinnitus interfere with your job or household responsibilities? | _ | _ | _ |
| 14 | Because of your tinnitus do you find that you are irritable? | _ | _ | _ |
| 15 | Because of your tinnitus is it difficult for you to read? | _ | _ | _ |
| 16 | Does your tinnitus make you upset? | _ | _ | _ |
| 17 | Do you feel that your tinnitus has placed stress on your relationships with friends or family members? | _ | _ | _ |
| 18 | Do you find it difficult to focus your attention away from your tinnitus? | _ | _ | _ |
| 19 | Do you feel you have no control over your tinnitus? | _ | _ | _ |
| 20 | Because of your tinnitus do you feel tired? | _ | _ | _ |
| 21 | Because of your tinnitus do you feel depressed? | _ | _ | _ |
| 22 | Does your tinnitus make you feel anxious? | _ | _ | _ |
| 23 | Do you feel you can no longer cope with your tinnitus? | _ | _ | _ |
| 24 | Does your tinnitus get worse when you are under stress? | _ | _ | _ |
| 25 | Does your tinnitus make you feel insecure? | _ | _ | _ |
Scoring:
0-16: Slight or no handicap (grade 1)
18-36: Mild handicap (grade 2)
38-56: Moderate handicap (grade 3)
58-76: Severe handicap (grade 4)
78-100: Catastrophic handicap (grade 5)