TinniTest.org
All questionnaires

Permission-free clinical use questionnaire

Tinnitus Sample Case History Questionnaire

A structured 35-item tinnitus case-history profile covering onset, sound characteristics, modifying influences, hearing, and related conditions.

Questions
35
Time
10 min
Privacy
Local only
Structured profile—not a diagnostic test.This case-history form has no total score or automated diagnosis. Complete it to organize a conversation with a qualified clinician. Name and date of birth are deliberately not collected here. Source and rights.

Section 1

Background

01Age
02Gender
03Handedness
04Family history of tinnitus complaints

Section 2

Tinnitus history

05Initial onset: When did you first experience your tinnitus?
06How did you perceive the beginning?
07Was the initial onset of your tinnitus related to:
08Does your tinnitus seem to pulsate?
09Where do you perceive your tinnitus?
10How does your tinnitus manifest itself over time?
11Does the loudness of the tinnitus vary from day to day?
12Describe the loudness of your tinnitus (1 = very faint; 100 = very loud)
13Please describe in your own words what your tinnitus usually sounds like

Examples include hissing, ringing, pulsing, buzzing, clicking, cracking, tonal, humming, popping, roaring, rushing, typewriter, whistling, or whooshing.

14Does your tinnitus sound more like a tone or more like noise?
15Please describe the pitch of your tinnitus
16What percent of your total awake time, over the last month, have you been aware of your tinnitus?
%
17What percent of your total awake time, over the last month, have you been annoyed, distressed, or irritated by your tinnitus?
%
18How many different treatments have you undergone because of your tinnitus?

Section 3

Modifying influences

19Is your tinnitus reduced by music or by certain environmental sounds such as a waterfall or running water?
20Does the presence of loud noise make your tinnitus worse?
21Does any head and neck movement, or having your arms/hands or head touched, affect your tinnitus?
22Does taking a nap during the day affect your tinnitus?
23Is there any relationship between sleep at night and your tinnitus during the day?
24Does stress influence your tinnitus?
25Does medication have an effect on your tinnitus? List medication and effect/details.

Section 4

Related conditions

26Do you think you have a hearing problem?
27Do you wear hearing aids?
28Do you have a problem tolerating sounds because they often seem much too loud?
29Do sounds cause you pain or physical discomfort?
30Do you suffer from headache?
31Do you suffer from vertigo or dizziness?
32Do you suffer from temporomandibular disorder?
33Do you suffer from neck pain?
34Do you suffer from other pain syndromes?
35Are you currently under treatment for psychiatric problems?

Create a private summary

Prepare your response profile

No total or severity band will be added.

Source, rights, and limitations

Permission-free clinical use. The Tinnitus Research Initiative distributes the English form for clinician and researcher use and describes its database project as open to participants who follow its consensus. TinniTest preserves the questions while omitting name and date-of-birth fields to reduce unnecessary personal data.

TinniTest.org is independent. Citation and reproduction do not imply author, institution, publisher, VA, or government endorsement.