Before your visit or between appointments, complete the questionnaires and history forms that match your concern. Your answers are saved for your care team.
Choose to set your path: history form first, then the related questionnaires.
Your reason for visit:
To see the forms related to you, first choose your reason for visit.
Choose a reasonIf you have tinnitus, these forms help your clinician understand severity and impact.
Medical history forms
This form asks about the type and severity of your tinnitus, aggravating/relieving factors, and its effect on sleep and concentration.
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Assessment questionnaires
Measures the degree of handicap caused by tinnitus across functional, emotional, and catastrophic domains. 25 items answered Yes, Sometimes, or No.
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Comprehensive assessment of the impact of tinnitus on daily life, sleep, concentration, and emotions. 52 items answered Yes, Partly, or No.
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Assesses tinnitus annoyance and its effect on speech perception, social interactions, and emotions. 27 items rated on a 0–100 scale.
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Measures tinnitus annoyance severity on a 100-millimetre visual analogue line.
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For dizziness and balance issues, complete the forms below.
Medical history forms
Please describe the type of dizziness, duration and frequency of attacks, accompanying symptoms, and the impact on daily activities.
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Assessment questionnaires
Evaluates the impact of dizziness on physical, emotional, and functional aspects of life. 25 items answered Yes, Sometimes, or No.
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If you have hearing loss, record your history and details with this form.
Medical history forms
Please answer about your hearing loss, when it started, medications and noise exposure. More precise answers lead to a better assessment.
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Assessment questionnaires
Screens for perceived hearing handicap in older adults (10 items) — a screening tool, not a diagnostic test.
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Revised hearing handicap screening set (10 items) — referral is recommended at a score of 6 or higher.
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Auditory processing screening based on the Buffalo Model (48 scored items; completed by a parent or teacher).
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This questionnaire screens for anxiety and depression related to ear and balance problems.
Assessment questionnaires
Screens for anxiety (7 items) and depression (7 items) in non-psychiatric populations. Cut-off score: 11.
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