5-MINUTE HEARING SURVEY
|#||Test||Almost Always||Half the time||Occasionally||Never|
I have a problem hearing over the phone.
I have trouble following the conversation when two or more people are
talking at the same time.
People complain that I turn the TV volume too high.
I have to strain to understand conversations.
I have trouble hearing conversations in a noisy background such as a party.
I miss hearing some common sounds like the phone or doorbell ring.
I get confused about where sounds come from.
I misunderstand some words in a sentence and need to ask people to repeat
I especially have trouble understanding the speech of women and children.
I have worked in noisy environments.
Many people mumble when they talk.
People get annoyed because I misunderstand what is being said.
I misunderstand what others are saying and make inappropriate responses.
I avoid social activities because I cannot hear well and fear that I’ll
To be answered by a family member
Do you think this person has a hearing loss?
Do you have a blood relative with hearing loss?
Please fill in the above form. Every answer will help.