| Question: | Answer | Total |
| 1. I have a problem hearing over the
telephone. |
|
|
| 2. I have trouble following the
conversation when two or more people are talking at the same time. |
|
|
| 3. People complain that I turn the
TV volume too high. |
|
|
| 4. I have to strain to understand
conversations. |
|
|
| 5. I miss hearing some common sounds
like the phone or the doorbell ringing. |
|
|
| 6. I have trouble hearing
conversations in a noisy background such as a party. |
|
|
| 7. I get confused about where sounds
come from. |
|
|
| 8. I misunderstand some words in a
sentence and need to ask people to repeat themselves. |
|
|
| 9. I especially have trouble
understanding the speech of women and children. | | |
| 10. I have worked in noisy
environments (assembly lines, jackhammers, jet engines, etc.) | | |
| 11. I hear fine - if people just
speak clearly. | | |
| 12. People get annoyed because I
misunderstand what they say. | | |
| 13. I avoid social activities
because I cannot hear well and fear I'll reply improperly. | | |
| 14. I misunderstand what others
are saying and make inappropriate responses. | | |
| To be answered
by a family member or friend: | | |
| 15. Do you think this person has
a hearing loss? | | |
| 16. If you have a blood relative
who has a hearing loss, add three points. | | |
