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.