5-MINUTE HEARING SURVEY

#	Test	Almost Always	Half the time	Occasionally	Never
1	I have a problem hearing over the phone.	.	.	.	.
2	I have trouble following the conversation when two or more people are talking at the same time.	.	.	.	.
3	People complain that I turn the TV volume too high.	.	.	.	.
4	I have to strain to understand conversations.	.	.	.	.
5	I have trouble hearing conversations in a noisy background such as a party.	.	.	.	.
6	I miss hearing some common sounds like the phone or doorbell ring.	.	.	.	.
7	I get confused about where sounds come from.	.	.	.	.
8	I misunderstand some words in a sentence and need to ask people to repeat themselves.	.	.	.	.
9	I especially have trouble understanding the speech of women and children.	.	.	.	.
10	I have worked in noisy environments.	.	.	.	.
11	Many people mumble when they talk.	.	.	.	.
12	People get annoyed because I misunderstand what is being said.	.	.	.	.
13	I misunderstand what others are saying and make inappropriate responses.	.	.	.	.
14	I avoid social activities because I cannot hear well and fear that I’ll reply improperly.	.	.	.	.

To be answered by a family member

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

Please fill in the above form. Every answer will help.