One-to-one conversation

1. Can you hear the phone ring from another room?  Yes      No

2. When speaking on the phone to a familiar speaker, is it difficult to hear?  Yes      No

3. When speaking on the phone to an unfamiliar speaker, is it difficult to hear?  Yes      No

4. Can you hear the doorbell or knock?  Yes      No

Small group conversation

1. Do you have difficulty following conversations with more than two people?  Yes      No

2. Do you often ask others to repeat themselves?  Yes      No

3. Do you have trouble understanding the voices of certain women and children?  Yes      No

4. Does it often sound like people are mumbling?  Yes      No

Workplace meetings

1. Do you have difficulty hearing certain people in business meetings in quiet meeting rooms?  Yes      No

2. Does it sometimes appear to others that you’re not paying attention?  Yes      No

3. Does it sometimes appear to others that you are lacking your usual keen insight?  Yes      No

4. Are you fully capable of relating to people one-on-one but experiencing difficulty relating to people in groups?  Yes      No

Outdoor activities (biking, walking, playing)

1. Can you hear conversation when conducted out of doors with soft background noise?  Yes      No

2. Can you hear conversation when conducted out of doors with loud background noise?  Yes      No

3. Can you hear traffic noise?  Yes      No

Watching television

1. Do others complain that you’re playing the television or radio too loud?  Yes      No

Listening to music

1. Are you able to enjoy the full spectrum of sound in music, or do you feel you’ve lost the ability to hear certain frequencies—such as high notes?  Yes      No

Work or recreational noise

1. When there is background noise, are you still able to understand the speech of someone near you?  Yes      No

2. Do you feel fatigue, irritability, negativism, anger, tension, stress or depression that may be related to the effort it takes to hear, understand and communicate appropriately?  Yes      No

Parties and social gatherings

1. Do you feel stressed out from straining to hear what others are saying?  Yes      No

2. Do you feel annoyed at people because you can’t hear or understand them?  Yes      No

3. Do you feel embarrassed to meet new people because you may misunderstand what they’re saying?  Yes      No

4. Do you feel nervous about trying to hear or understand?  Yes      No

At a restaurant

1. Do you ever feel embarrassed because you have misunderstood conversation and responded inappropriately?  Yes      No

Place of worship/theater

1. Can you understand the speech of the speaker at a place of worship, at the movies and theater?  Yes      No

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