To request an appointment at NYOG by email, please give us your contact information in the form below and we will get back to you shortly with available dates.
You can also call the office:
212.889.8575
We take most insurance plans. Please call the office
to see if we accept yours.
Tinnitus Treatment NYC Questionnaire | Assessing Tinnitus
212.889.8575
2 Manhattan, NYC Offices
Most Major Insurance Accepted
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ULTHERAPY
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New York Sinus Center
- Sinusitis
- Sinusitis Signs & Symptoms
- Underlying Causes of Sinusitis
- Sinusitis Diagnosis & Treatment
- Sinus Surgery
- Radiology and Sinus Disorders
- What to Expect from Sinus Surgery
- Anosmia / Loss of Smell
- Sinusitis FAQ
- Doctors
- Questionnaires and Forms
- Links
Head and Neck Surgery Center
- Head & Neck Cancer
- Cancer & Tobacco
- Other Risk Factors
- Head and Neck Cancer Symptoms
- Mouth Cancer Diagnosis and Treatment
- Surgery
- Head and Neck Surgery Rehabilitation
- Parathyroid Disease
- Parathyroid Disease Symptoms
- Parathyroid Disease Diagnosis and Treatment
- Parathyroid Disease Surgery
- Thyroid Disorders
- Benign Thyroid Tumors
- Thyroid Cancer
- Diagnosis & Treatment
- Head & Neck Cancer Surgery FAQ
- Questionnaires and Forms
- Links
Hearing & Balance Center
- Hearing Disorders
- Hearing Loss
- Ear Pain
- Ear Infections (Otitis Media) in Children
- Otosclerosis Symptoms, Causes, and Treatment
- Cholesteatoma – Symptoms, Diagnosis, and Treatment
- Ossicular Chain Discontinuity
- Ear Drum Surgery for Perforations
- Autoimmune Inner Ear Disease
- Vertigo & Balance Disorders
- Meniere’s Disease
- Tinnitus Causes and Treatment
- Hearing Loss Causes
- Hearing Loss Treatment
- Hearing Preservation for Musicians
- Hearing Aids
- Halo Hearing Aid
- Implantable Hearing Devices
- Bone Anchored Hearing Aids (BAHAs)
- Cochlear Implants (CI)
- Earlens Light-Driven Hearing Aid
- Ear Surgery
- Stapedotomy Surgery
- Ossicular Chain Reconstruction
- Ear Tube Surgery
- How the Ear Works
- Online Hearing Test
- Testimonials
- Questionnaires and Forms
- Glossary
- Links
New York Voice Center
- Voice
- Diagnosis
- Treatment
- Pitch Lowering Surgery to Alter Voice
- Speech
- Speech Diagnosis
- Speech Therapy and Training
- Swallowing
- Diagnosis
- Treatment
- The Professional Voice
- Diagnosis
- Treatment
- FAQ's
- Doctors
- Questionnaires and Forms
- Links
Facial Plastics Center
- About
- ULTHERAPY
- Information for Patients – Cosmetic Surgery
- Rhinoplasty (Plastic Surgery) – Preparing and What to Expect
- Browlift
- Eyelid Surgery
- Facelift Surgery
- Facial Implants Preparation, Day of Surgery, and Post-Operative Care
- Photo Galleries
- Fat Transfer
- Cosmetic Rhinoplasty
- Nasal Trauma
- Blepharoplasty
- Facelift
- Nasal Valve Reconstruction
The New York Otolaryngology Group
Questionnaires and Forms
Tinnitus Reaction Questionnaire
Tinnitus Reaction Questionnaire
This questionnaire is designed to find out what sort of effects tinnitus has had on your lifestyle, general well-being, etc. Some of the effects below may apply to you, some may not. Please answer
all
questions by circling the number that
best reflects
how your tinnitus has affected you
over the past week
Rank your responses from
0 - Not at all
to
4 - Almost all of the time
Name
First
Last
Email
Phone
My tinnitus has made me unhappy
0
1
2
3
4
My tinnitus has made me feel tense
0
1
2
3
4
My tinnitus has made me feel irritable
0
1
2
3
4
My tinnitus has made me feel angry
0
1
2
3
4
My tinnitus has led me to cry
0
1
2
3
4
My tinnitus has led me to avoid quiet situations
0
1
2
3
4
My tinnitus has made me feel less interested in going out
0
1
2
3
4
My tinnitus has made me feel depressed
0
1
2
3
4
My tinnitus has made me feel annoyed
0
1
2
3
4
My tinnitus has made me feel confused
0
1
2
3
4
My tinnitus has "driven me crazy"
0
1
2
3
4
My tinnitus has interfered with my enjoyment of life
0
1
2
3
4
My tinnitus has made it hard for me to concentrate
0
1
2
3
4
My tinnitus has made it hard for me to relax
0
1
2
3
4
My tinnitus has made me feel distressed
0
1
2
3
4
My tinnitus has made me feel helpless
0
1
2
3
4
My tinnitus has made me feel frustrated with things
0
1
2
3
4
My tinnitus has interfered with my ability to work
0
1
2
3
4
My tinnitus has led me to despair
0
1
2
3
4
My tinnitus has led me to avoid noisy situations
0
1
2
3
4
My tinnitus has led me to avoid social situations
0
1
2
3
4
My tinnitus has made me feel hopeless about the future
0
1
2
3
4
My tinnitus has interfered with my sleep
0
1
2
3
4
My tinnitus has led me to think about suicide
0
1
2
3
4
My tinnitus has made me feel panicky
0
1
2
3
4
My tinnitus has made me feel tormented
0
1
2
3
4
Total
If you have ranked any of these questions with a high score, please
log in to our Patient Portal and schedule an appointment with us
or call our office at
212-889-8575
I would like a scheduler from your office to contact me:
By Phone
By Email
I do not want to be contacted. I will contact you.
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