1. HEARING QUESTIONNAIRE

    N = NEVER, S = SOMETIMES, A = ALMOST ALWAYS PLEASE ANSWER WITH AN A, S OR N.

    1. Do you have a problem hearing or understanding TV ?                          _____

    2. Do you have a problem understanding conversation when in groups

    or  other social environments?                                                           _____

    3. Do you have difficulty understanding what people are saying when

    they are more than 12 feet away?                                                    _____

    4. Do you have problems understanding speech on the telephone?         _____

    5. Do friends and family mumble?                                                               _____

    6. Do you have a problem hearing the lyrics in popular songs?                  _____

    7. Do you have a problem hearing the turn signal in your car ?                  _____

    8. Do you have a problem hearing in a restaurant or at a meeting?           _____

    9. Do you have a problem hearing birds and other nature sounds when

    you are walking or working outside?                                                 _____

    10. Do you have more difficulty understanding women’s or children’s

    higher pitch and softer voices?                                                          _____

    11. Do you hear ringing in you ears?                                                           _____

    12. Do you hear mostly in one ear?                                                             _____

    13. Ever worked around loud noise?                                                            _____

    14. Have you often been asked to turn down the TV?                                 _____

    15. Have you had an earache and/or drainage from your ear?                    _____

    *-when scoring A = 2, S = 1, N= 0

    ** The higher the score the greater the possibility that a hearing loss exists.

    A complete hearing evaluation is recommended.

                                                                                                           Total score:   _____

     

     

    Siemens has developed a short accurate screening test.  Take this test by clickinghttp://hearing.siemens.com/_resources/dispenser-hearing-test/usa/hearing-test.html

If you are not sure you have a hearing loss and never had a hearing test take a few minutes to take these two tests.  You may find them interesting.

After testing please contact us.We would like to discuss your results.