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.