Tinnitus Connect – Patient Intake

Tinnitus Connect

Patient Intake Portal

1

Patient Info

2

Tinnitus Questionnaire

Patient Intake Form

Please fill in your details accurately. All fields marked * are required.

Personal Information

First Name * Required

Last Name * Required

Date of Birth * Required

Gender

Email Address * Valid email required

Phone Number

City / Location

Tinnitus History

How long have you had tinnitus? * Required

Affected Ear(s)

Primary Sound Type

Is it constant or intermittent?

Associated Conditions

Do you experience any of the following? (select all that apply)

Previous Treatments

What treatments have you tried? (if any)

What triggered your tinnitus? (if known)

Anything else you'd like us to know?