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Self Test: The purpose of the self-test is to identify the problems a hearing loss may be causing. Print this page then answer either Yes, Sometimes, or No for each of the questions. Do not skip a question if you avoid a situation because of a hearing problem. See below for scoring.
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Please read each question and check the box that applies to you.
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Yes
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Sometimes
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No
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Does a hearing problem cause you to feel embarrassed when meeting new people?
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Does a hearing problem cause you to feel frustrated when talking to members of your family?
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Do you have difficulty hearing when someone speaks in a whisper?
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Do you feel handicapped by a hearing problem?
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Does a hearing problem cause you difficulty when visiting with friends, relatives or neighbors?
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Does a hearing problem cause you difficulty in the movies, the theater or when attending religious services?
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Does a hearing problem cause you to have arguments with family members?
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Does a hearing problem cause you difficulty when listening to TV or radio?
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Do you feel that any difficulty with your hearing limits or hampers your personal or social life?
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Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?
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Using the scoring formula shown below calculate the total number of points scored
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Scoring
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Yes = 4 pts
Sometimes = 2 pts
No = 0 pts
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If you scored higher than 8 points on this questionnaire, it is highly recommended that you make an appointment for a hearing evaluation conducted by a professional hearing health care provider. If you suspect a hearing loss, call your doctor, or visit the Audiology Service Associates location nearest you. We can help!
Please note: Some web browsers may have a difficulty printing the questionnaire on a single page. You may lose one or more lines of the the questionnaire. If you have this problems click here for a more printer friendly version of this questionnaire.
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