Questionnaire for tinnitus/hyperacusis Name 1. Which year were you born? * 2. Are you female or male? * Female Male 3. Which year and month did your tinnitus start? 4. Which year and month did you get hyperacusis? 5. Did you also get sudden deafness when you got tinnitus/hyperacusis? Yes No 6. Which ear is affected? Left Right Both 7. What sounds are you particularly sensitive to? 8. Choose one or several of the following options to describe your tinnitus: Constant swoosh Swoosh coming and going Constant beep Beep coming and going Beep varying in frequency Changing between swoosh and beeping Strong Weak Other 8a. If you prefer, describe your tinnitus in your own words: 9. Is your sleep affected by the tinnitus? Yes No 10. To what extent is your everyday life affected by your tinnitus/hyperacusis? Not at all Not much Quite a lot A lot My whole everyday life is affected 11. Do you refrain from doing certain activities due to your tinnitus/hyperacusis? No Yes, to a certain extent Yes, a lot 12. Have been on sick leave due to your tinnitus/hyperacusis? No Yes, part time Yes, full time 13. Do you think you were stressed when you got the tinnitus/hyperacusis? Yes No 14. Do you think the muscles in the neck, throat and/or shoulders were tense when you got the tinnitus/hyperacusis? Yes No 15. What do you think has caused your tinnitus/hyperacusis? 16. Are there any activities that make your tinnitus/hyperacusis worse? Yes No 17. Is there anything that makes your tinnitus/hyperacusis more bearable? Yes No 18. Does your tinnitus/hyperacusis occasionally disappear completely or to a certain extent? Yes No 19. Has your tinnitus affected you to such an extent that you have contemplated committing suicide? No Yes Several times 20. Has the situation ever been so bad that you actually tried taking your own life? Yes No 21. What do you do for work before the problems developed? 22. Do you think you are/were exposed for loud noise at your workplace? Yes No 23. Approximately how many hours are or were you exposed to loud noise during a working day? Not at all Less than five Five or more 24. Approximately how many years have you worked with this or had other jobs with exposure to loud noise? 25. Do you have or have you had any leisure activities where you are/were exposed to loud noise? Yes No 26. Do/did you use any kind of ear protection when exposed to loud noise? No Sometimes Always 28. Have you tried acupuncture? Yes No 29. Have you tried massage? Yes No 30. Do you use or have you used barbitone due to the tinnitus? Yes No 31. Have you tried any herbal drugs? Yes No 32. Have you tried antidepressants? Yes No 33. Have you tried CBT? Yes No 34. Have you consulted a physiotherapist for any other treatment of the tinnitus? Yes No 35. Have you tried any other treatment? Yes No 36. Is there anything you would like to add or comment on? 37. Can we contact you for follow up questions if we consider that appropriate? Yes No
