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.
- 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
- 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
1 = Mild problem
2 = Moderate problem
3 = Severe problem
Time's up