| Name: |
|
| Email: |
|
| Phone Number: |
|
Find out immediately if it’s a good idea to see an audiologist. It’s optional to leave your contacting info. Strongly Disagree = 0 Strongly Agree = 4 |
I have a problem hearing over the telephone |
0
|
1
|
2
|
3
|
4
|
I have trouble following the conversation when two or more people are talking at the same time |
0
|
1
|
2
|
3
|
4
|
I have trouble understanding things on TV |
0
|
1
|
2
|
3
|
4
|
I have to strain to understand conversations |
0
|
1
|
2
|
3
|
4
|
I have to worry about missing a telephone ring or doorbell |
0
|
1
|
2
|
3
|
4
|
I have trouble hearing conversations in a noisy background such as a crowded room or a restaurant |
0
|
1
|
2
|
3
|
4
|
I get confused about where sound comes from. |
0
|
1
|
2
|
3
|
4
|
I misunderstand some words in a sentence and need to ask people to repeat themselves. |
0
|
1
|
2
|
3
|
4
|
I especially have trouble understanding the speech of women and children. |
0
|
1
|
2
|
3
|
4
|
I have trouble understanding the speaker in a large room such as at a meeting or place of worship |
0
|
1
|
2
|
3
|
4
|
Many people I talk to seem to mumble (or don't speak clearly). |
0
|
1
|
2
|
3
|
4
|
People get annoyed because I misunderstand what they say |
0
|
1
|
2
|
3
|
4
|
I misunderstand what others are saying and make inapropriate responses |
0
|
1
|
2
|
3
|
4
|
I avoid social activities because I cannot hear well and fear I will reply improperly |
0
|
1
|
2
|
3
|
4
|
Family members and friends have told me they think I may have a hearing loss. |
0
|
1
|
2
|
3
|
4
|
| |
|
|
