1) Do you have trouble understanding conversation in a noisy restaurant or crowded room?

o Yes o No o Sometimes

2) Do you sometimes feel that people are mumbling or not speaking clearly?

o Yes o No o Sometimes

3) Do you experience difficulty fol­lowing dialog in the theater?

o Yes o No o Sometimes

4) Do you sometimes find it difficult to understand a speaker at a pub­lic meeting or a religious service?

o Yes o No o Sometimes

5) Do you find yourself asking people to speak up or repeat themselves?

o Yes o No o Sometimes

6) Do you find men’s voices easier to understand than women’s?

o Yes o No o Sometimes

6) Do you experience difficulty understanding soft or whispered speech?

o Yes o No o Sometimes

7) Do you have difficulty understand­ing speech on the telephone?

o Yes o No o Sometimes

8 ) Does a hearing problem cause you to feel embarrassed when meeting new people?

o Yes o No o Sometimes

9) Do you feel handicapped by a hearing problem?

o Yes o No o Sometimes

10 Does a hearing problem cause you to visit friends, relatives, or neighbors less often than you would like?

o Yes o No o Sometimes

11) Do you experience ringing or noises in your ears?

o Yes o No o Sometimes

12) Do you hear better with one ear than the other?

o Yes o No o Sometimes

13) Have you had any significant noise exposure during work, recreation, or military service?

o Yes o No

14) Have any of your relatives (by birth) had a hearing loss?

o Yes o No

Scoring

2 points for Yes

1 point for Sometimes

0 points for No

Scores of 3 or more: May mean that you have a hearing problem.

Scores of 6 or more: Strongly suggest that a hearing check is warranted.