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- Dr. Vincent Penza
- Dr. Katherine Morioka
Eye Care Services
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Binocular Vision Dysfunction (BVD)
Hours & Directions
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Home » Sound Sensitivity Questionnaire

Sound Sensitivity Questionnaire

Patient Name
First Last
Date
Date Format: MM slash DD slash YYYY
1. Do you have trouble concentrating in a noisy environment?
- Yes
- Sometimes
- No
2. Do you have trouble reading in a noisy or loud environment?
- Yes
- Sometimes
- No
3. Do you ever use earplugs or earmuffs to reduce your noise perception?
(Do not consider the use of hearing protection during abnormally high exposure situations.)
- Yes
- Sometimes
- No
4. Do you find it harder to ignore sounds around you in everyday situations?
- Yes
- Sometimes
- No
5. Do you find it difficult to listen to speaker announcements (such as airport, airplanes, trains, etc.)?
- Yes
- Sometimes
- No
6. Are you particularly sensitive to or bothered by street noise?
- Yes
- Sometimes
- No
7. Do you automatically cover your ears in the presence of somewhat louder sounds?
- Yes
- Sometimes
- No
8. When someone suggests doing something (going out, to the cinema, to a concert, etc.) do you immediately think about the noise you are going to have to put up with?
- Yes
- Sometimes
- No
9. Do you ever turn down an invitation or not go out because of the noise you would have to face?
- Yes
- Sometimes
- No
10. Do you find the noise unpleasant in certain social situations (e.g., nightclubs, pubs or bars, concerts, firework displays, cocktail receptions)?
- Yes
- Sometimes
- No
11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly?
- Yes
- Sometimes
- No
12. Are you particularly bothered by sounds others are not?
- Yes
- Sometimes
- No
13. Are you afraid of sounds others are not?
- Yes
- Sometimes
- No
14. Do noise and certain sounds cause you stress and irritation?
- Yes
- Sometimes
- No
15. Are you less able to concentrate in noise toward the end of the day?
- Yes
- Sometimes
- No
16. Do stress and tiredness reduce your ability to concentrate in noise?
- Yes
- Sometimes
- No
17. Do you find sounds annoy you and not others?
- Yes
- Sometimes
- No
18. Are you emotionally drained by having to put up with all daily sounds?
- Yes
- Sometimes
- No
19. Do you find daily sounds having an emotional impact on you?
- Yes
- Sometimes
- No
20. Are you irritated by sounds others are not?
- Yes
- Sometimes
- No

Patient History Form

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City Optometry

530 Bush St #101
San Francisco, CA 94108

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:30 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

NOTE: On Saturdays, the doctor is available from 9:00 am - 2:30 pm. The Optical Boutique is open from 9:00 am - 4:00 pm.

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City Optometry - Located at 530 Bush St #101, San Francisco, CA, 94108. Phone: 415-291-8560 . https://www.city-optometry.com

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Eye Care Services
Eyewear & Contacts
Binocular Vision Dysfunction (BVD)
Hours & Directions
Insurance

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