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NOTE: For those suffering from tinnitus, once you have completed this form please click on the Tinnitus Handicap Inventory link and complete the form.

First and Last name (required)

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Main complaint (required)

Secondary complaint (if applicable)

When did your symptoms begin? (required)

Have you had a recent hearing test, if yes when? (required)

If you have tinnitus rate the loudness from 1 (extremely soft) to 10 (very loud):

What percentage of your waking hours are you aware of the tinnitus? (Tinnitus patients only)

Possible cause of tinnitus:

Previous treatment (if any):

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Our office hours are 9 AM- 5:30 PM Pacific Time. We will contact you within 48 hours of completing this questionnaire.

You may reach us at 310-559-4884, if you need further assistance.

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