Tinnitus Questionnaire | soulessense coaching and hypnotherapy

Thank you for your interest in this research survey!

This questionnaire is suitable for you if you experience tinnitus, have seen your doctor about this before and are over 18 years of age.

The purpose of this questionnaire is a) to collect and analyse data about tinnitus and its impact in general, and b) find suitable participants for a small-scale study that will be used to research how hypnosis can help reduce or remove tinnitus, either through live hypnosis sessions or hypnosis recordings.

Any answers will be confidential and used only for research purposes. If you sign up for communications with us, your email address and name will be added to our email system separate from the survey data. Aggregated data from this survey will be published anonymously. You have the right to withdraw your contribution and/or application at any time while filling in the form by simply leaving the page, or emailing inquiries@soulessense.co to let us know.

You will be able to enter your name and email at the end to apply as a candidate for the hypnosis case study. To remain anonymous, simply leave the fields blank.

Should you apply as a candidate for one or several 1 on 1 hypnosis sessions, be aware that you will need to fill in a second follow-up questionnaire, sessions will be recorded and may be published in full or in parts – with only your first name in the video. Participation via hypnosis audios will also require you to fill in a second follow-up questionnaire.

This project is not funded by any university or organization. The responsible party is soulessense coaching and hypnotherapy.

The total questionnaire will take about 10-20 minutes to complete.

Thank you for taking the time!

This questionnaire consists of 3 parts. Parts A and B are a standard tinnitus questionnaire called ESIT-Q.

Part C are questions specific to this study.

A1 How old are you?

A2 What is your gender?

A3/4 What is your Body-Mass-Index? (calculate on https://www.calculator.net/bmi-calculator.html)

A5 What is the highest education level you have achieved?

A6 What is the average number of alcoholic drinks you consume per week? One drink equals 125ml of wine, 330ml of beer or 40ml of spirits.

A7 Which of the following best describes your smoking status?

A8 How many first degree relatives (parents, children, siblings) do you know to have tinnitus or hearing loss?

A9 Do you suffer from vertigo (sensation of spinning or tilting)?

A11 Have you ever undergone any of the following procedures? You can choose more than one option.

A11-2 Please specify which other procedure you have undergone

A12 Over the last week, have external sounds been a problem, being too loud or uncomfortable for you when they seemed normal to others around you? Note: external sounds refer to any sounds other than tinnitus, e.g. environmental sounds, speech, music.

A13 Do you currently have any other difficulty with your hearing, such as listening to speech in a noisy situation?

A14 Do you use any of the following devices? You can choose more than one option.

A15 Do you suffer from any of the following pain syndromes? You can choose more than one option.

A15-2 Please specify which other pain syndrome you suffer from.

A17 Tinnitus refers to the perception of noise in your head or ears (such as ringing or buzzing) in the absence of any corresponding source of sound external to your head. Over the past year, have you had tinnitus in your head or in one or both ears that lasts for more than five minutes at a time?

B1 How often do you have tinnitus on average?

B2 What best describes your tinnitus during a day?

B3 How long ago did your tinnitus appear?

B4 Over the past year, how much does your tinnitus worry, annoy or upset you when it is at its worst?

B5 How long ago did your tinnitus start bothering you?

B6 Although most patients have tinnitus of a single type, some may hear different sounds. Do you hear one or more different sounds?

B7 How was the start of your tinnitus?

B8 If you reported any conditions/procedures in questions A9, A10, A11, A12, A13, A15 or A16, please list them here and write next to them if they happened BEFORE, AFTER, or at about the SAME TIME as your tinnitus onset.

B9a Please specify if you chose OTHER in question B9

B10a Please specify your answer from question B10 if you said "other"

B11 Do you think any of the conditions mentioned before or any other conditions are related to your tinnitus onset?

B11a Please specify your answer from question B11. You can choose up to 3 conditions, please start with the most important.

B12 Is the loudness of your tinnitus stable over time or does it fluctuate over a day?

B13 What does your tinnitus sound like?

B13a Please specify if you chose OTHER in question 13

B14 Please describe the pitch of your tinnitus:

High pitched Medium pitched Low pitched Do not know

B15a Please specify if you chose OTHER in question 15

B16 Is your tinnitus rhythmic?

No Yes, following heart beat (can be checked by feeling the pulse at the same time as listening to the tinnitus) Yes, following breathing Yes, following movements of the head, neck, jaw or muscles of the face Other. Please specify in the next section

B17 Has a clinician ever heard your tinnitus?

B18a Please specify if you chose OTHER in question 18

B19a Please specify if you chose OTHER in question 19

B20 Over the past year, have you seen your family doctor, or seen a healthcare professional at a clinic or hospital about your tinnitus?

B21 Are you currently receiving any of the following types of management for your tinnitus? You can choose more than one option.

B22 Do you think any of the conditions mentioned before, or any other conditions, are related to periods of increased tinnitus?

B22a Please specify your answer from question B22. You can choose up to 3 conditions, please start with the most important.

C1 How does your tinnitus impact you in daily life?

C2 On a scale of 0-10, with 10 being the worst, how bad is your tinnitus in general?

C3 On a scale of 0-10, with 10 being the worst, how bad is your tinnitus when it's low?

C4 On a scale of 0-10, with 10 being the worst, how bad is your tinnitus when it's at its loudest?

C5 What have you been told or learned about your tinnitus (from doctor, media, other sources)?

C6 How strongly do you agree with the following: Tinnitus can go away on its own.

C7 How strongly do you agree with the following: Medical treatments can significantly reduce tinnitus symptoms.

C8 How strongly do you agree with the following: Psychological treatments can significantly reduce tinnitus symptoms.

C9 How strongly do you agree with the following: My tinnitus will improve over time.

C10 How much does tinnitus affect your daily life?

C12 Have you ever had hypnosis for any condition before?

C12a If you answered yes to question 12, did you find it helpful?

C13 Have you heard of hypnosis as treatment for tinnitus?

C14 How strongly do you agree: Hypnosis can help reduce the symptoms of tinnitus.

C15 How strongly do you agree: I am willing to use hypnosis for tinnitus relief

What do you know about hypnosis?

Name (only fill in if you would like to apply as study participant)

Email (only fill in if you would like to apply as study participant or receive email communications)

Application as Study Participant

Yes, I want to apply as potential participant for a case study on tinnitus and am willing to fill in one or more forms after. I have read the terms and conditions of this website. I do not have any other medical or psychological issues or take medication that might interfere with hypnotherapy sessions. Alternatively, if I do, I will disclose them before a potential session and/or provide a note from my medical provider that I can take part in a hypnosis session or hypnosis audio recordings without any problem. I will be contacted if selected. I am aware that filling in this form does not give me the legal right to any services or participation whatsoever, and there will be a selection process.

Consent to Video

If I am chosen as subject for hypnosis, I am aware that sessions will be recorded on video. Sessions may be made available publicly whole or in part as video, transcript or case study, without disclosing my full name.

Consent to Data Use

I agree to my answers being used for this study in anonymous form and for results to be published. I can withdraw this consent at any time by emailing inquiries@soulessense.co

GDPR

I also agree to my email address and name to be added to soulessense's email list and receiving marketing communications.