Tinnitus Functional Index

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

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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