I have a problem hearing over the telephone.

Yes No

I have trouble following the conversation when two or more people are talking at the same time.

Yes No

I have trouble understanding things on TV.

Yes No

I have to worry about missing a telephone ring or doorbell.

Yes No

I have to strain to understand conversations.

Yes No

I have trouble hearing conversations in a noisy background such as a crowded room or restaurant.

Yes No

I get confused about where sounds come from.

Yes No

I misunderstand some words in a sentence and need to ask people to repeat themselves.

Yes No

I especially have trouble understanding the speech of women and children.

Yes No

I have trouble understanding the speaker in a large room such as at a meeting or place of worship.

Yes No

People get annoyed because I misunderstand what they say.

Yes No

I misunderstand what others are saying and make inappropriate responses.

Yes No

I avoid social activities because I cannot hear well and fear I will reply inappropriately.

Yes No

Family members and friends have told me they think I may have a hearing loss.

Yes No

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