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Tinnitus Initial Profile

Pre-Assessment Screening

Tinnitus Initial Profile

A structured pre-assessment questionnaire

Before we discuss your tinnitus in detail, this brief questionnaire helps us understand your tinnitus pattern, functional impact, previous investigations and treatment experience.

Important Clinical Notice: This questionnaire is an initial screening and information-gathering tool. It does not provide a diagnosis and does not replace appropriate medical evaluation or treatment. Your responses will be reviewed to determine whether a comprehensive tinnitus assessment may be appropriate.

1 About You

2 Your Tinnitus

3 Patterns

4 Impact

5 Hearing & Care

6 Safety

7 Next Step

Step 1 of 7 — About You 14%

Step 1 of 7

About You

Please provide your contact details so our clinical team can review your responses.

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Initial Screening & Information-Gathering Tool

This questionnaire is an initial screening and information-gathering tool. It does not provide a diagnosis and does not replace appropriate medical evaluation or treatment. Your responses will be reviewed to determine whether a comprehensive tinnitus assessment may be appropriate.

I understand that this is an initial screening questionnaire and not a diagnosis. *

Full Name *

Age * (Minimum 18)

Country *

City / State / Region (Optional)

Email Address * We will send your review summary to this address.

Preferred Communication Method *

Email WhatsApp Other

Specify other communication method

How did you find Nexynaptics? *

Specify other referral source

Step 2 of 7

Your Tinnitus

Understanding the duration, perception location, sound qualities, and continuity of your tinnitus.

How long have you experienced tinnitus? *

Less than 1 month 1–6 months 6–12 months 1–3 years More than 3 years I don't remember

Where do you perceive the tinnitus? *

Left ear Right ear Both ears Inside my head It changes location Other

Specify other perception location

How would you describe the sound? * (Select all that apply)

Ringing Buzzing Hissing Static / electrical Pulsing / throbbing Clicking Multiple sounds Other

Specify other sound description

Is your tinnitus: *

Continuous Intermittent Both / varies

Describe your tinnitus in your own words (Optional)

Step 3 of 7

What Changes Your Tinnitus?

Tinnitus is frequently modulated by somatosensory movements, physical posture, environmental sound levels, or physiological stress.

Does your tinnitus change with any of the following?

Clenching your jaw

Yes No Not sure

Opening your mouth

Yes No Not sure

Moving your jaw sideways

Yes No Not sure

Moving your neck

Yes No Not sure

Touching or pressing around your jaw/neck

Yes No Not sure

Stress

Yes No Not sure

Fatigue

Yes No Not sure

Poor sleep

Yes No Not sure

Loud sounds

Yes No Not sure

Quiet environments

Yes No Not sure

Exercise

Yes No Not sure

Certain body positions

Yes No Not sure

What makes your tinnitus better or less noticeable? (Optional)

What makes your tinnitus worse or more noticeable? (Optional)

Step 4 of 7

Functional Impact

How is tinnitus affecting your daily life? Rate each domain from 0 (Not affected) to 10 (Severely affected).

Sleep Falling asleep, night waking, or overall sleep quality

0 / 10