The following THREE questionnaires are for completion by those who have been referred to our Audiology Department’s Tinnitus Service. 

It is important that you answer ALL THREE questionnaires. Once you have pressed 'submit' for the Tinnitus Functional Index form there are two further forms below named 'H.A.D.S Questionnaire' and the ‘Insomnia Severity Index’ that should also be completed. You will also need to press ‘submit’ for each of these questionnaires.

They are an important part of measuring the extent of your tinnitus problem and you will be asked to repeat them prior to any further appointments, so that we can follow the progress of your tinnitus management.

Please complete the questionnaires BEFORE each appointment, so that there is enough time in the appointment to discuss your needs and to start your tinnitus management programme.

If you have any difficulty completing the questionnaires, or would like to request them in paper format instead, please contact our Audiology Department on 0191 569 9001, or at stsft.audiology@nhs.net.

Tinnitus Functional Index

Please read each question below carefully. To answer a question, select ONE of the numbers that is listed for that question. Please answer each question based on your experiences over the past week.

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Over the past week...

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Over the PAST WEEK, how much has your tinnitus interfered with the below factors. 0 being did not interfere and 10 being completely interfered.

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Over the PAST WEEK…

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We cannot guarantee the information submitted in this form will be transferred securely to the Trust and you submit this at your own risk.

H.A.D.S. Questionnaire

Please read each item below and choose the reply that comes closest to how you have been feeling in the past week.

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Questions

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We cannot guarantee the information submitted in this form will be transferred securely to the Trust and you submit this at your own risk.

Insomnia Severity Index

Please rate the current (i.e. last two weeks) severity of your insomnia problem(s):

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Questions

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We cannot guarantee the information submitted in this form will be transferred securely to the Trust and you submit this at your own risk.

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