| Date: ________________ | Name: _____________________________ | |||
| Symptom | Rarely (Less than monthly) |
Sometimes (At least monthly) |
Often (At least weekly) |
Always (At least daily) |
| 1) Does a hearing problem cause you to feel embarrassed when meeting new people? | ___ | ___ | ___ | ___ |
| 2) Does a hearing problem cause you to feel frustrated when talking to members of your family? | ___ | ___ | ___ | ___ |
| 3) Do you have difficulty hearing when someone whispers? | ___ | ___ | ___ | ___ |
| 4) Do you feel handicapped by a hearing problem? | ___ | ___ | ___ | ___ |
| 5) Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? | ___ | ___ | ___ | ___ |
| 6) Does a hearing problem cause you to attend religious services less often than you would like? | ___ | ___ | ___ | ___ |
| 7) Does a hearing problem cause you to have arguments with family members? | ___ | ___ | ___ | ___ |
| 8) Does a hearing problem cause you difficulty when listening to TV or radio? | ___ | ___ | ___ | ___ |
| 9) Do you feel that your hearing limits or hampers your personal or social life? | ___ | ___ | ___ | ___ |
| 10) Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? | ___ | ___ | ___ | ___ |