This form is designed for people suffering from hyperacusis. Please complete the form and submit it so that we can provide the best treatment options possible for your specific needs.

Full Name

Your Phone Number

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Have you filled out the new patient form?

Are you also experiencing tinnitus?

1. Do you have trouble concentrating in a loud or noisy environment?

2. Do you have trouble reading in a noisy or loud environment?

3. Do you ever use earplugs or earmuffs to reduce your noise perception? (Do not consider the use of hearing protection during abnormally high exposure situations.)

4. Do you find it harder to ignore sounds around you in everyday situations?

5. Do you find it difficult to listen to speaker announcements (such as airport, airplanes, trains etc.)?

6. Are you particularly sensitive to or bothered by street noise?

7. Do you automatically cover your ears in the presence of somewhat louder sounds?

8. When someone suggests doing something (going out, to the cinema, to a concert, etc.) do you immediately think about the noise you are going to have to put up with?

9. Do you ever turn down an invitation or not go out because of the noise you would have to face?

10. Do you find the noise unpleasant in certain social situations (e.g. nightclubs, pubs or bars, concerts, firework displays, cocktail receptions)?

11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly?

12. Are you particularly bothered by sounds others are not?

13. Are you afraid of sounds others are not?

14. Do noise and certain sounds cause you stress and irritation?

15. Are you less able to concentrate in noise toward the end of the day?

16. Do stress and tiredness reduce your ability to concentrate in noise?

17. Do you find sounds annoy you and not others?

18. Are you emotionally drained by having to put up with all daily sounds?

19. Do you find daily sounds having an emotional impact on you?

20. Are you irritated by sounds others are not?

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