Adult Hyperacusis Questionaire Adult Hyperacusis QuestionaireThese questions are about EVERYDAY & ENVIRONMENTAL SOUNDS (not tinnitus)Full NameDate Of Birth MM slash DD slash YYYY Location for which you are filling the formChoose locationCalgaryHigh RiverLethbridgeGrande PrairieForm completed by Self Parent Other1. Do you have trouble concentrating in a noisy or loud environment? Yes Sometimes No2. Do you have trouble reading in a noisy or loud environment? Yes Sometimes No3. 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.) Yes Sometimes No4. Do you find it harder to ignore sounds around you in everyday situations? Yes Sometimes No5. Do you find it difficult to listen to speaker announcements (such as airport, airplanes, trains, etc.)? Yes Sometimes No6. Are you particularly sensitive to or bothered by street noise? Yes Sometimes No7. Do you “automatically” cover your ears in the presence of somewhat louder sounds? Yes Sometimes No8. 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? Yes Sometimes No9. Do you ever turn down an invitation or not go out because of the noise you would have to face? Yes Sometimes No10. Do you find the noise unpleasant in certain social situations (e.g., nightclubs, pubs or bars, concerts, firework displays, cocktail receptions)? Yes Sometimes No11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly? Yes Sometimes No12. Are you particularly bothered by sounds others are not? Yes Sometimes No13. Are you afraid of sounds that others are not? Yes Sometimes No14. Do noise and certain sounds cause you stress and irritation? Yes Sometimes No15. Are you less able to concentrate in noise toward the end of the day? Yes Sometimes No16. Do stress and tiredness reduce your ability to concentrate in noise? Yes Sometimes No17. Do you find sounds annoy you and not others? Yes Sometimes No18. Are you emotionally drained by having to put up with all daily sounds? Yes Sometimes No19. Do you find daily sounds having an emotional impact on you? Yes Sometimes No20. Are you irritated by sounds others are not? Yes Sometimes NoAny Additional Comments:
