Tinnitus Functional Index

Please read each question below carefully. To answer a question, select ONE of the numbers that is listed for that question.

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First Name

Last Name

Over the PAST WEEK…

What percentage of your time awake were you consciously AWARE OF your tinnitus?

0% – Never aware

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% – Always aware

How STRONG or LOUD was your tinnitus?

0 – Not at all strong or loud

10 – Extremely strong or loud

What percentage of your time awake were you ANNOYED by your tinnitus?

0% – None of the time

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% – All of the time

Over the PAST WEEK…

Did you feel IN CONTROL in regard to your tinnitus?

0 – Very much in control

10 – Never in control

How easy was it for you to IGNORE your tinnitus?

0 – Very easy to ignore

10 – Impossible to ignore

How easy was it for you to COPE with your tinnitus?

0 – Very easy to cope

10 – Impossible to cope

Over the PAST WEEK, how much did your tinnitus interfere with…

Your ability to CONCENTRATE?

0 – Did not interfere

10 – Completely interfered

Your ability to THINK CLEARLY?

0 – Did not interfere

10 – Completely interfered

Your ability to FOCUS ATTENTION on other things besides your tinnitus?

0 – Did not interfere

10 – Completely interfered

Over the PAST WEEK…

How often did your tinnitus make it difficult to FALL ASLEEP or STAY ASLEEP?

0 – Never had difficulty

10 – Always had difficulty

How often did your tinnitus cause you difficulty in getting AS MUCH SLEEP as you needed?

0 – Never had difficulty

10 – Always had difficulty

How much of the time did your tinnitus keep you from SLEEPING as DEEPLY or as PEACEFULLY as you would have liked?

0 – None of the time

10 – All of the time

Over the PAST WEEK, how much has your tinnitus interfered with…

Your ability to HEAR CLEARLY?

0 – Did not interfere

10 – Completely interfered

Your ability to UNDERSTAND PEOPLE who are talking?

0 – Did not interfere

10 – Completely interfered

Your ability to FOLLOW CONVERSATIONS in a group or at meetings?

0 – Did not interfere

10 – Completely interfered

Over the PAST WEEK, how much has your tinnitus interfered with…

Your QUIET RESTING ACTIVITIES?

0 – Did not interfere

10 – Completely interfered

Your ability to RELAX?

0 – Did not interfere

10 – Completely interfered

Your ability to enjoy “PEACE AND QUIET”?

0 – Did not interfere

10 – Completely interfered

Over the PAST WEEK, how much has your tinnitus interfered with…

Your enjoyment of SOCIAL ACTIVITIES?

0 – Did not interfere

10 – Completely interfered

Your ENJOYMENT OF LIFE?

0 – Did not interfere

10 – Completely interfered

Your RELATIONSHIPS with family, friends and other people?

0 – Did not interfere

10 – Completely interfered

How often did your tinnitus cause you to have difficulty performing your WORK OR OTHER TASKS, such as home maintenance, school work, or caring for children or others?

0 – Never had difficulty

10 – Always had difficulty

Over the PAST WEEK…

How ANXIOUS or WORRIED has your tinnitus made you feel?

0 – Not at all anxious or worried

10 – Extremely anxious or worried

How BOTHERED or UPSET have you been because of your tinnitus?

0 – Not at all bothered or upset

10 – Extremely bothered or upset

How DEPRESSED were you because of your tinnitus?

0 – Not at all depressed

10 – Extremely depressed

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