Do you find it difficult to follow a conversation in a noisy restaurant or crowded room?
Yes No Sometimes
Do you sometimes feel that people are mumbling or not speaking clearly?
Yes No Sometimes
Do you experience difficulty following dialog in the theater?
Yes No Sometimes
Do you sometimes find it difficult to understand a speaker at a public meeting or a religious service?
Yes No Sometimes
Do you find yourself asking people to speak up or repeat themselves?
Yes No Sometimes
Do you find men's voices easier to understand than women's?
Yes No Sometimes
Do you experience difficulty understanding soft or whispered speech?
Yes No Sometimes
Do you sometimes have difficulty understanding speech on the telephone?
Yes No Sometimes
Does a hearing problem cause you to feel embarrassed when meeting new people?
Yes No Sometimes
Do you feel handicapped by a hearing problem?
Yes No Sometimes
Does a hearing problem cause you to visit friends, relatives or neighbors less often than you would like?
Yes No Sometimes
Do you experience ringing or noises in your ears?
Yes No Sometimes
Do you hear better with one ear than the other?
Yes No
Have you had any significant noise exposure during work, recreation or military service?
Yes No
Have any of your relatives (by birth) had a hearing loss?
Yes No
