Education Center

Hearing Questionnaire

Take this brief questionnaire to evaluate your hearing loss. Upon completion, please call one of our clinics to review your results. We will be happy to meet with you to discuss a variety of custom solutions.

		Almost Always	Half the time	Occasionally	Never
1.	I have a problem hearing over the phone.
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 have trouble hearing conversations in a noisy background such as a party.
6.	I miss hearing some common sounds like the phone or doorbell ring.
7.	I get confused about where sounds come from.
8.	I misunderstand some words in a sentence and need to ask people to repeat them.
9.	I especially have trouble understanding the speech of women and children.
10.	I have worked in noisy environments.
11.	Many people mumble when they talk.
12.	People get annoyed because I misunderstand what is being said.
13.	I misunderstand what others are saying and make inappropriate responses.
14.	I avoid social activities because I cannot hear well and fear that I'll reply improperly.
To be answered by a family member :
15.	Do you think this person has a hearing loss?
16.	Do you have a blood relative with hearing loss?	yes	no

 

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Last Name *

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