Tinnitus Evaluation

Tinnitus Evaluation Form

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Once you have submitted the following form one of our Tinnitus Specialists will contact you with your results.

Your Name (required)

Your Email (required)

Your Phone (required)

Have you been bothered by your tinnitus (ringing, buzzing, hissing, pounding, or other noises in your ears) for more than 50% of your waking hours over the past week?

 Yes No

Has your tinnitus interfered with your sleep?

 Yes No

Has your tinnitus interfered with your enjoyment of life?

 Yes No

Has your tinnitus made you feel irritable?

 Yes No

Has your tinnitus made it hard for you to relax?

 Yes No

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