Enter: 4 for a “yes” answer; 2 for “sometimes”; 0 for a “no” answer

1. Does a hearing problem cause you to feel embarrassed when you
meet 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 speaks in a whisper? _____

4. Do you feel handicapped by a hearing problem? _____

5. Does a hearing problem cause you to attend religious services less
often than you would like? _____

6. Does a hearing problem cause you difficulty when visiting friends,
relative or neighbors? _____

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 any difficulty with 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? _____

TOTAL _____

Interpretation of Results:

• If the total score is in the 0 to 9 range, the probability of significant hearing loss is minimal.
• If the total score is in the 10 to 24 range, the scores suggests a mild to moderate impairment in communication and an audiologic evaluation to further evaluate the cause and severity of the hearing loss.
• If the total score is in the 25 to 40 range, there is significant indication of communication impairment / hearing loss, and an audiologic evaluation is recommended to further evaluate the cause and severity of hearing loss.