Hearing Test

5-Minute Hearing Survey

1. I have a problem hearing over the phone.
Almost AlwaysHalf the timeOccasionallyNever
2. I have trouble following the conversation when two or more people are talking at the same time.
Almost AlwaysHalf the timeOccasionallyNever
3. People complain that I turn the TV volume too high.
Almost AlwaysHalf the timeOccasionallyNever
4. I have to strain to understand conversation.
Almost AlwaysHalf the timeOccasionallyNever
5. I have trouble hearing conversation in a noisy background such as a party.
Almost AlwaysHalf the timeOccasionallyNever
6. I miss hearing some common sounds like the phone or doorbell ring.
Almost AlwaysHalf the timeOccasionallyNever
7. I get confused about where sounds come from.
Almost AlwaysHalf the timeOccasionallyNever
8. I misunderstand some words in a sentence and need to ask people to repeat themselves.
Almost AlwaysHalf the timeOccasionallyNever
9. I especially have trouble understanding the speech of women and children.
Almost AlwaysHalf the timeOccasionallyNever
10. I have worked in noisy environments.
Almost AlwaysHalf the timeOccasionallyNever
11. Many people mumble when they talk.
Almost AlwaysHalf the timeOccasionallyNever
12. People get annoyed because I misunderstand what is being said.
Almost AlwaysHalf the timeOccasionallyNever
13. I misunderstand what others are saying and make inappropriate responses.
Almost AlwaysHalf the timeOccasionallyNever
14. I avoid social activities because I cannot hear well and fear that I'll reply improperly.
Almost AlwaysHalf the timeOccasionallyNever

To be answered by a family member

15. Do you think this person has a hearing loss?
YESNO
16. Do you have a blood relative with hearing loss?
YESNO

Please fill in the above form with your personal information below. Every answer will help.


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