Please select an answer for each question. If you wear a hearing aid, answer according to how you do without the hearing aid.
Do you 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
Do you 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
Do you 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
Do you 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
Do you 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
Do you 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
Do you feel that any difficulty with your hearing limits or hampers your 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 your hearing upset you?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Do others suggest that you have a hearing problem?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
Do others leave you out of conversations or become annoyed because of your hearing?
Never/Almost never
Occasionally (25% of time)
Half the time
Frequently (75% of time)
Always/mostly always
