| Almost Always | Half the time | Occasionally | Never | ||
|---|---|---|---|---|---|
| 1. | Do you have difficulty hearing when background noise is present? | ||||
| 2. | Do you misunderstand what people are saying? | ||||
| 3. | Do you have difficulty hearing and/or understanding children? | ||||
| 4. | Do you have ringing in your ears? | ||||
| 5. | Do you have difficulty understanding speech in a group of people? | ||||
| 6. | Do you often ask that statements, questions or directions be repeated? | ||||
| 7. | Do you hear people speaking, but have difficulty understanding the words? | ||||
| 8. | Must others raise their voices or move closer to help you hear them? | ||||
| 9. | Do you turn the television up louder than normal to hear clearly? | ||||
| 10. | Do you have to concentrate so much to listen that you tire from it? | ||||
| 11. | Do you ever avoid a situation because you may not be able to hear well? | ||||
| 12. | Do you have difficulty understanding conversations in the car? | ||||
| 13. | Do you have difficulty understanding conversations on the telephone? |
