Please select an answer for each question. If he/she wears a hearing aid, answer according to how they do without the hearing aid.
Does he/she experience communication difficulties in situations when speaking with one other person? (for
example, at home, at work, in a social situation, with a waitress, a store clerk, with a spouse, boss, etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she experience communication difficulties in situations when conversing with a small group of several
people? (for example, with friends or family, co-workers, in meetings or casual conversations, over dinner or while playing cards,
etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she experience communication difficulties while listening to someone speak to a large group? (for
example, at a church or civic meeting, in a fraternal or women's club, at an educational lecture, etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she experience communication difficulties while participating in various types of entertainment? (for
example, movies, TV, radio, plays, night clubs, musical entertainment, etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she experience communication difficulties when you are in an unfavorable listening environment? (for
example, at a noisy party, where there is background music, when riding in an auto or bus, when someone whispers or talks from across
the room, etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she experience communication difficulties when using or listening to various communication devices?
(for example, telephone ring, doorbell, public address system, warning signals, alarms, etc.)
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does he/she feel that any difficulty with your hearing limits or hampers his/her personal or social life?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Does any problem or difficulty with his/her hearing upset them?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Do others suggest that he/she has a hearing problem?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Do others leave him/her out of conversations or become annoyed because of his/her hearing?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
