HEARING LOSS QUESTIONNAIRE

Please answer the following questions. If the answer is "yes" to two or more questions, hearing loss may be indicated. Ask your doctor for a referral form to order a thorough audiologic evaluation.

ADULT HEARING LOSS QUESTIONNAIRE:

Please answer the following:

Do you often miss certain words when others are talking? Yes No

Do you frequently ask the speaker to repeat what was said? Yes No

Have family members or friends expressed concern about your hearing? Yes No

Do you avoid certain social situations (ex. theaters, restaurants, parties) because it s too difficult to hear? Yes No

Do you have difficulty understanding telephone conversations? Yes No

Do you turn up the TV or radio to volume levels that are too loud for others? Yes No

Do you hear better in one ear than in the other? Yes No

Do you have difficulty following conversations in groups or in the presence of background noise? Yes No

Do you experience ringing or buzzing sounds in one or both ears? Yes No

CHILD HEARING LOSS QUESTIONNAIRE:

Parents, please answer the following:

Have you ever questioned your child's ability to hear normally? Yes No

Does your child watch your face when you speak? Yes No

Is the TV too loud for you when your child is allowed to adjust the volume himself/herself? Yes No

Has your child had a history of ear infections? Yes No

Is your child's speech understood by family members, but not by others? Yes No

Does your child try to sit as close as possible to the TV? Yes No

Have you or teachers noticed a change in your child's behavior at home / school? (uncooperative, doesn't follow directions, "daydreams" in classroom) Yes No