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.) |
|
| 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.) |
|
| 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.) |
|
| Does he/she experience communication
difficulties while participating in various types of
entertainment? (for example, movies, TV, radio, plays, night
clubs, musical entertainment, etc.) |
|
| 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.) |
|
| 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.) |
|
| Does he/she feel that any difficulty with
your hearing limits or hampers his/her personal or social life? |
|
| Does any problem or difficulty with
his/her hearing upset them? |
|
| Do others suggest that
he/she has a
hearing problem? |
|
| Do others leave
him/her out of conversations or become annoyed because of his/her hearing? |
|
