Tinnitus Program Form

1010 N. Davis Street, Suite 101 Jacksonville, FL 32209

Tel: 904.355.3403 Fax: Tel:904.355.4149 Email: clinic@shcjax.org
Welcome to Jacksonville Speech & Hearing Center!

Thank you for your interest in our tinnitus program. We understand how difficult it is to cope with constant tinnitus and how it can affect even basic day-to-day tasks. We want you to know that our doctors of audiology are here to help you navigate the information available about tinnitus, including possible treatment or management options.

Enclosed is an outline of our tinnitus program. It details everything from a basic overview of tinnitus to detailed appointment pricing. After reviewing this information, if you’d like to set up a consultation with one of our doctors, please email the requested information to clinic@shcjax.org and we’ll reach out to you to get your consultation scheduled as soon as possible.

Due to the high volume of requests that we receive for tinnitus information, our doctors are not available to discuss additional details about the program without a scheduled consultation. Additionally, information cannot be provided regarding your specific needs without the requested information and time to review it.

We hope that you find the enclosed documents informative and we look forward to working with you through your tinnitus challenges.

Warmest Regards,

Jacksonville Speech & Hearing Center Staff

Audiology Tinnitus Program

General Tinnitus Information

Tinnitus is commonly considered a ringing sound presented in the ear. While it is most often described by patients as a ringing, it is important to note that it can occur as other sounds like whirling, hissing, whooshing, pulsing, buzzing, music, and crackling.

Tinnitus can be intermittent or constant. Most individuals will experience at least some tinnitus throughout their lifetime as no more than a minor annoyance. Others will have more severe cases that cause disruption to their daily activities.

While the true cause of tinnitus is difficult to determine, it is generally accepted as a symptom of something else. When developing a treatment plan for tinnitus, your doctor is going to look at which of your symptoms, diagnostics and other health factors are most likely contributing to the tinnitus symptoms. When addressing all health concerns known to relate to tinnitus, many individuals find relief from their symptoms. There is no known “cure” for tinnitus; however, there are treatment options that can help develop habits and coping tools to help reduce or manage the symptoms.

The stressful and negative nature of tinnitus often creates feelings of helplessness or hopelessness, especially when discovering there is no proven cure available today. If you are feeling discouraged about the lack of options for tinnitus treatment, we want you to know that we understand and we are here for you.
How to Get Started

There are two very critical parts to this program that you’ll need to commit to prior to contacting us for your consultations. First, prepare your mind to start fresh today. Don’t hold on to any preconceived notions or frustrations of the past. Second, this program requires you to be dedicated to a solution. You must be a compliant patient. Treatment may require developing new habits or getting rid of some old ones. It will likely also require some patience. This treatment is not an overnight process.

We’re going to need some healthcare history and possibly some diagnostics for an evaluation and consultation. Enclosed within this document are a tinnitus inventory questionnaire and a health factors inventory. They will need to be completed and submitted to the doctor, along with any supporting diagnostic documents. This will need to be done at least one week prior to your consultation.

The program is best when conducted in-person but can also be conducted remotely (by phone or video) if the situation calls for those accommodations and as long as all of the needed information can be provided.

Tinnitus Inventory

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When did you first become aware of having Tinnitus? *
If you have hyperacusis (hypersensitivity to loud sounds), when were you first aware of this problem? *
In which ear is your tinnitus (right, left, both, not in the ears, in the head)? *
If your tinnitus is in both ears, is one side louder than the other? *
What does your tinnitus sound like (e.g., ringing, crickets, humming, etc)? *
Is the volume of tinnitus stable, or does it change? *
Is it a pulsing sound that changes in time with your heart beat?
What seems to make the tinnitus change?
Is it made worse by exposure to a sound? *
If so, how long does it stay bad after sound exposure?
List all methods, procedures, medications, or devices you have tried for your tinnitus, and the treatment outcomes.
Have you seen ear specialists about your Tinnitus? How many
If you have been seen by hearing specialists what were you told?
Do you have hearing loss? *
If you do have hearing loss please describe
Do you have hearing aids? *
Are you uncomfortable with certain sounds? *
Do you wear ear protection (plugs or muffs)? *
If you do wear ear protection, about what percentage of time do you wear them?
Do you wear ear protection in quiet situations? *
Do you experience pain in the ears from loud sounds? *
Have you ever worked anywhere that exposed you to continuous loud noise? *
Estimate the percentage of time over the past month that you have been aware of the tinnitus? *
Estimate the percentage of time over a month period (not counting sleeping) when you are:
In a quiet environment (e.g., quiet home; you can be understood even when speaking softly) *
Moderate environment (e.g., average street, office, restaurant) *
Loud environment (noisy work place, very loud radio or TV) *

Health Factors Inventory
Approximate Onset of Tinnitus: *
Previously Diagnosed Health Concerns

Instructions: The purpose of this section is to identify any health concerns that may contribute to tinnitus symptoms. If you have any of these health concerns, please use the space within the block for notes regarding the condition. Provide details regarding type of condition and how long you’ve experienced it. When submitting this inventory to us, please also submit any supporting documents from the treating providers.

Health Condition

	Approximate Diagnosis Date	Not Treating	Currently Treating or Managing	Treatment Complete
Heart Condition
Blood Sugar
Blood Pressure
Weight/Nutrition
Hearing Loss
Excessive Noise Exposure (work or recreational)
Mental Health
Cancer
Current Level of Exercise
Current Medications
Other Conditions

Mental Health Resources
Tinnitus is more than a ringing in your ear. For many, it affects your mental health. We want to make sure you are successful in managing every aspect of your tinnitus. Working with a counselor to develop health compensatory strategies is highly recommended. Below are some resources that we recommend looking into. For on-going counseling, you may want to contact your insurance carrier for assistance identifying someone that is in your network or covered by insurance.

Emergency Line
If you are having self-harming or suicidal thoughts, immediately call 911.

National Suicide Prevention Lifeline: 800-273-8255
Available 24 hours. Languages: English, Spanish. Learn more

Crisis Text Line: Text HOME to 741741 to connect with a Crisis Counselor
Available 24 hours

Veteran Crisis Line: 800-273-8255, Press 1, Text Message to 838255
Chat Online: https://www.veteranscrisisline.net/
Available 24 hours to all veterans and service members, their family and friends

Professional Counselling
These counselors or groups are known to have therapists on staff that specialize in CBT, ART or Tinnitus patients. Please contact the confirm acceptance of insurance or self-pay rates.

D'Arienzo Psychology (904) 379-8094
11512 Lake Mead Ave #704 · In Hampton Village Office Park
https://www.drdarienzo.com/

Beaches Therapy - DBT & Mindfulness Center (904) 299-3420
1552 Roberts Dr, Jacksonville Beach, FL
https://www.beachestherapy.com/

Beaches Cognitive Behavioral Therapy (904) 447-1467
Louis R. Franzini, Ph.D.
https://www.louisfranzini.com/

Jacksonville Center For Counseling (904) 737-7242
3560 Cardinal Point Dr SUITE # 204
http://jacksonvillecenterforcounseling.com/

Non-profit counseling providers can be found on https://www.opencounseling.com/florida/jacksonville

Check with your employer to see if they have an EAP with counseling benefits.
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	Yes (4 Points)	Sometimes (2 Points)	No (0 Points)
Because of your tinnitus, is it difficult for you to concentrate?
Does the loudness of your tinnitus make it difficult for you to hear people?
Does your tinnitus make you angry?
Does your tinnitus make you feel confused?
Because of your tinnitus, do you feel desperate?
Do you complain a great deal about your tinnitus?
Because of your tinnitus, do you have trouble falling to sleep at night?
Because of your tinnitus, do you have trouble falling to sleep at night? Do you feel as though you cannot escape your tinnitus?
Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies)?
Because of your tinnitus, do you feel that you have a terrible disease?
Does your tinnitus make it difficult for you to enjoy life?
Does your tinnitus interfere with your job or household responsibilities?
Because of your tinnitus, do you find that you are often irritable?
Because of your tinnitus, is it difficult for you to read?
Does your tinnitus make you upset?
Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?
Do you find it difficult to focus your attention away from your tinnitus and on other things?
Do you feel that you have no control over your tinnitus?
Because of your tinnitus, do you often feel tired?
Because of your tinnitus, do you feel depressed?
Does your tinnitus make you feel anxious?
Do you feel that you can no longer cope with your tinnitus?
Does your tinnitus get worse when you are under stress?
Does your tinnitus make you feel insecure?

	Yes	No	Not Sure
Concentration
Falling Asleep
Staying Asleep
Restaurants
Social Events
Church
Sports Events
Quiet Activities
Concerts
Other

1010 N. Davis Street, Suite 101 Jacksonville, FL 32209

Tinnitus Inventory

Tinnitus Inventory

Health Factors Inventory

Mental Health Resources