1. Because of your tinnitus, is it difficult for you to concentrate?
yes
sometimes
no

2. Does the loudness of your tinnitus make it difficult for you to hear people?
yes
sometimes
no

3. Does your tinnitus make you angry?
yes
sometimes
no

4. Does your tinnitus make you feel confused?
yes
sometimes
no

5. Because of your tinnitus, do you feel desperate?
yes
sometimes
no

6. Do you complain a great deal about your tinnitus?
yes
sometimes
no

7. Because of your tinnitus, do you have trouble falling to sleep at night?
yes
sometimes
no

8. Do you feel as though you cannot escape your tinnitus?
yes
sometimes
no

9. Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies)?
yes
sometimes
no

10. Because of your tinnitus, do you feel frustrated?
yes
sometimes
no

11. Because of your tinnitus, do you feel that you have a terrible disease?
yes
sometimes
no

12. Does your tinnitus make it difficult for you to enjoy life?
yes
sometimes
no

13. Does your tinnitus interfere with your job or household responsibilities?
yes
sometimes
no

14. Because of your tinnitus, do you find that you are often irritable?
yes
sometimes
no

15. Because of your tinnitus, is it difficult for you to read?
yes
sometimes
no

16. Does your tinnitus make you upset?
yes
sometimes
no

17. Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?
yes
sometimes
no

18. Do you find it difficult to focus your attention away from your tinnitus and on other things?
yes
sometimes
no

19. Do you feel that you have no control over your tinnitus?
yes
sometimes
no

20. Because of your tinnitus, do you often feel tired?
yes
sometimes
no

21. Because of your tinnitus, do you feel depressed?
yes
sometimes
no

22. Does your tinnitus make you feel anxious?
yes
sometimes
no

23. Do you feel that you can no longer cope with your tinnitus?
yes
sometimes
no

24. Does your tinnitus get worse when you are under stress?
yes
sometimes
no

25. Does your tinnitus make you feel insecure?
yes
sometimes
no