Do you have hearing loss?

 Hearing Loss Questionnaire * 

 Instructions: Answer Yes, No, or Sometimes for each question. Do not skip a question if you avoid a situation because of a hearing problem. If you use a hearing aid, please answer according to the way you hear with the aid. 

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 difficulty when visiting friends, relatives, or neighbors? 
6. Does a hearing problem cause you to attend religious services less often than you would like? 
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? 

 Scoring: No = 0; Sometimes = 2; Yes = 4. 

Interpretation of Total Score:
0-8 = no handicap; 10-24 = mild to moderate handicap; 26-40 = severe handicap. 

 * Adapted from: Ventry I, Weinstein B. Identification of elderly people with hearing problems. ASHA. 1983; 25:37-42.