Free resource
Your appointment, on one clear page.
Copy a blank tinnitus worksheet into Notes, download it as editable text, or print it. No account, app, or purchase needed.
The template below is ready to use.
Bring what you know. Leave room for questions.
This is an organization aid, not a validated questionnaire or a way to decide which care you need. Sudden hearing loss needs immediate medical care; do not wait to finish a diary. Seek emergency care for tinnitus with new facial weakness or spinning dizziness, or after a head injury.
Fill in your copy offline. This page has no health-note input or upload. This worksheet is separate from OtoNote Pro exports.
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.
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Our guides show clearly labeled fictional examples. They are not patient records, clinical conclusions, or screenshots of an app export.
View the filled fictional examplePrepared by the OtoNote product team, Borealbit Technology Limited. Updated October 11, 2026. Not independently reviewed by a clinician.
Sources checked October 10, 2026: NIDCD Tinnitus, NIDCD Sudden Deafness, NHS Tinnitus. The worksheet layout is our own, not a medical instrument endorsed by these organizations.
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