TINNITUS APPOINTMENT WORKSHEET
Organization aid, not a diagnostic checklist or validated questionnaire.
Complete what you know. Use "not recorded" for unknowns.

Period covered / appointment date: ___________________________
First noticed (date; sudden or gradual; unknown is okay):
____________________________________________________________
Sound description; side (left / right / both / unclear):
____________________________________________________________
Continuous or intermittent; heartbeat-like pulsing noticed?
____________________________________________________________
Hearing changes or other symptoms to discuss:
____________________________________________________________
Dated observations (optional personal 0–10 ratings, not clinical scores):
Date | Loudness | Bother | Impact on daily life / context
____________________________________________________________
____________________________________________________________
____________________________________________________________
Medication list / relevant history or test results to bring:
____________________________________________________________
Main questions for the clinician:
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________

Do not wait to finish this sheet before seeking care. Sudden
hearing loss needs immediate medical care. Seek emergency care
for tinnitus with new facial weakness or spinning dizziness,
or after a head injury. Ask promptly about heartbeat-like pulsing.
This sheet cannot triage you.

Free OtoNote website resource — not an app export.
https://otonote.borealbit.com/resources/appointment-worksheet
Sources: NIDCD Tinnitus; NIDCD Sudden Deafness; NHS Tinnitus.