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| ANSWER KEY: | A = Almost Always | B = Half The Time | C = Occasionally | D = Never | |
| 1. I have a problem hearing over the telephone. | |||||
| A | B | C | D | ||
| 2. I have trouble following the conversation when two or more people are talking at the same time. | |||||
| A | B | C | D | ||
| 3. People complain that my TV volume is too high. | |||||
| A | B | C | D | ||
| 4. I have to strain to understand conversations. | |||||
| A | B | C | D | ||
| 5. I miss hearing some common sounds like the telephone or doorbell ring. | |||||
| A | B | C | D | ||
| 6. I have trouble hearing conversations in a noisy background, such as a party. | |||||
| A | B | C | D | ||
| 7. I get confused about where sounds come from. | |||||
| A | B | C | D | ||
| 8. I misunderstand some words and need to ask people to repeat themselves. | |||||
| A | B | C | D | ||
| 9. I especially have trouble understanding the speech of woman and children. | |||||
| A | B | C | D | ||
| 10. I have worked in noisy
environments (such as assembly lines, construction sites, near jet engines, or military front lines). |
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| A | B | C | D | ||
| 11. Many people I talk to seem to mumble, or do not speak clearly. | |||||
| A | B | C | D | ||
| 12. People get annoyed because I misunderstand what they say. | |||||
| A | B | C | D | ||
| 13. I misunderstand what others are saying and make inappropriate responses. | |||||
| A | B | C | D | ||
| 14. I avoid social activities because I cannot hear well and fear I will make improper replies. | |||||
| A | B | C | D | ||
| 15. A family member or friend has suggested that maybe I have a hearing problem. | |||||
| A | B | C | D | ||
| Total Score: ________________ | |||||
| 3 points for each "A - Almost Always" answer | |||||
| 2 points for each "B - Half The Time" answers | |||||
| 1 point for each "C - Occasionally" answers | |||||
| 0 points for each "D - Never" answers | |||||
| If you scored 10 or more points, you should have your hearing tested. | |||||
| Source: American Academy of Otolaryngology | |||||