| 1 | F | Because of your tinnitus is it difficult for you to concentrate? |
| 2 | F | Does the loudness of your tinnitus make it difficult for you to hear people? |
| 3 | E | Does your tinnitus make you angry? |
| 4 | F | Does your tinnitus make you feel confused? |
| 5 | C | Because of your tinnitus do you feel desperate? |
| 6 | E | Do you complain a great deal about your tinnitus? |
| 7 | F | Because of your tinnitus do you have trouble falling to sleep at night? |
| 8 | C | Do you feel as though you cannot escape your tinnitus? |
| 9 | F | Does your tinnitus interfere with your ability to enjoy social activities(such as going out to dinner, to the movies)? |
| 10 | E | Because of your tinnitus do you feel frustrated? |
| 11 | C | Because of your tinnitus do you feel that you have a terrible disease? |
| 12 | F | Does your tinnitus make it difficult for you to enjoy life? |
| 13 | F | Does your tinnitus interfere with your job or household responsibilities? |
| 14 | E | Because of your tinnitus do you find that you are often irritable? |
| 15 | F | Because of your tinnitus is it difficult for you to read? |
| 16 | E | Does your tinnitus make you upset? |
| 17 | E | Do you feel that your tinnitus problem has placed stress on your relationship with members of your family and friends? |
| 18 | F | Do you find it difficult to focus your attention away from your tinnitus and on other things? |
| 19 | C | Do you feel that you have no control over your tinnitus? |
| 20 | F | Because of your tinnitus do you often feel tired? |
| 21 | E | Because of your tinnitus do you feel depressed? |
| 22 | E | Does your tinnitus make you feel anxious? |
| 23 | C | Do you feel that you can no longer cope with your tinnitus? |
| 24 | F | Does your tinnitus get worse when you are under stress? |
| 25 | E | Does your tinnitus make you feel insecure? |