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: _____ |