1. Do you have difficulty understanding voices on the telephone?

Yes
No

2. Do you have a hard time holding a conversation in a crowded place such as a restaurant?

Yes
No

3. Do your family members complain that you have the television too loud?

Yes
No

4. Do you frequently have to ask people to repeat themselves because you didn’t hear or understand their question?

Yes
No

5. Do you sometimes miss hearing everyday sounds like the doorbell or microwave chime?

Yes
No

6. When two or more people are talking at the same time, do the sounds become jumbled and undecipherable?

Yes
No

7. Do you have difficulty hearing women’s and/or children’s voices?

Yes
No

8. Do you find yourself straining to hear some conversations?

Yes
No

9. Does your family complain that you aren’t listening to them?

Yes
No

10. Are you able to hear when someone speaks in a whisper?

Yes
No

11. Does a hearing problem cause you to feel embarrassed when you meet new people?

Yes
No

12. Have you worked in a noisy environment?

Yes
No

13. Do you get confused about where sounds come from?

Yes
No

14. Does it seem like many people mumble when they talk?

Yes
No

15. Do you sometimes avoid social activities because you can’t hear well and fear that you’ll reply improperly?

Yes
No