1. Do you have difficulty hearing when background noise is present? YesNo
2. Do you misunderstand what people are saying? YesNo
3. Do you have difficulty hearing and/or understanding children? YesNo
4. Do you have ringing in your ears? YesNo
5. Do you have difficulty understanding speech in a group of people? YesNo
6. Do you often ask that statements, questions or directions be repeated? YesNo
7. Do you hear people speaking, but have difficulty understanding the words? YesNo
8. Must others raise their voices or move closer to help you hear them? YesNo
9. Do you turn the television up louder than normal to hear clearly? YesNo
10. Do you have to concentrate so much to listen that you tire from it? YesNo
11. Do you ever avoid a situation because you may not be able to hear well? YesNo
12. Do you have difficulty understanding conversations in the car? YesNo
13. Do you have difficulty understanding conversations on the telephone? YesNo
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