Hearing Survey

5 Minute Hearing Survey

		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
		YES	NO
15.	Do you think this person has a hearing loss?
16.	Do you have a blood relative with hearing loss?

2331 Velp Ave Ste G
Green Bay, WI 54303,
phone: 920-434-6777

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