Check “Sometimes,” “Yes,” or “No” for each question. Do not skip a question.	Sometimes	Yes	No
Because of your tinnitus, is it difficult for you to concentrate?	□	□	□
Does the loudness of your tinnitus make it difficult for you to hear people?	□	□	□
Does your tinnitus make you angry?	□	□	□
Does your tinnitus make you feel confused?	□	□	□
Because of your tinnitus, do you feel desperate?	□	□	□
Do you complain a great deal about your tinnitus?	□	□	□
Because of your tinnitus, do you have trouble falling to sleep at night?	□	□	□
Do you feel as though you cannot escape your tinnitus?	□	□	□
Does your tinnitus interfere with your ability to enjoy social activities?	□	□	□
Because of your tinnitus, do you feel frustrated?	□	□	□
Because of your tinnitus, do you feel that you have a terrible disease?	□	□	□
Does your tinnitus make it difficult for you to enjoy life?	□	□	□
Does your tinnitus interfere with your job or household responsibilities?	□	□	□
Because of your tinnitus, do you find that you are often irritable?	□	□	□
Because of your tinnitus, is it difficult for you to read?	□	□	□
Does your tinnitus make you upset?	□	□	□
Do you feel that your tinnitus problems have placed stress on your relationships?	□	□	□
Do you find it difficult to focus your attention away from your tinnitus and on other things?	□	□	□
Do you feel that you have no control over your tinnitus?	□	□	□
Because of your tinnitus, do you often feel tired?	□	□	□
Because of your tinnitus, do you feel depressed?	□	□	□
Does your tinnitus make you feel anxious?	□	□	□
Do you feel that you can no longer cope with your tinnitus?	□	□	□
Does your tinnitus get worse when you are under stress?	□	□	□
Does your tinnitus make you feel insecure?	□	□	□