Hearing Evaluation and Auditory Rehabilitation

How to complete this Questionnaire:

  • To let us know more about your hearing loss, please answer the following questions
  • There are no "right" or "wrong" answers, and only you can provide this information.
  • Because we want to know how you feel about your problems, whenever a statement represents an area or activity of your life where you have a problem, please indicate HOW MUCH OF A PROBLEM it is to you.
  • If a statement is not appropriate to your situation or if you are not having a problem in this area, circle the "0" and go on to the next statement.
  • If you are now wearing a hearing aid, please answer these questions thinking about your hearing loss and hearing aid.
  1. Considering how severe the problem is and how frequently it happens, please rate each item below on how “bad” it is by circling the number that corresponds with how you feel
  2. Please rank the 5 most important items affecting your health in the column to the right with a number 1 to 5 (maximum of 5 items)
0 = No problem
1 = Mild problem
2 = Moderate problem
3 = Severe problem
Speech muffled

Difficulty distinguishing direction of sounds

My intelligence or competency questioned due to my inability to completely hear others speak

Difficulty hearing speaker who is further away from me

Difficulty hearing telephone ring/alarm clock/door bel

Difficulty hearing when in a group or noisy situation

Difficulty communicating to family, friends, or others not familiar with my hearing problem

Difficulty communicating in car

Difficulty hearing on telephone

Difficultyhearing television or radio

Decreased enjoyment of music/movies/plays/outdoor performances / house of worship

Hearing loss causes frustration

Hearing loss causes embarrassment

Hearing loss causes increased anxiety or nervousness

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