Self Test Questionnaire

Check YES or NO or SOMETIMES for each question.

1. Do you find it difficult to follow a conversation in a noisy restaurant or crowded room?

Yes Sometimes No

2. Do you feel that people are mumbling or not speaking clearly?

Yes Sometimes No

3. Do you find it difficult to understand a speaker at a public meeting or a religious service?

Yes Sometimes No

4. Do you find yourself asking people to speak up or repeat themselves?

Yes Sometime No

5. Do you have difficulty understanding people on the telephone?

Yes Sometimes No

6. Does a hearing problem cause you to visit friends, relatives or neighbors less often than you would like?

Yes Sometimes No

7. Do you experience ringing or noises in your ears?

Yes Sometimes No

8. Do you hear better with one ear than the other?

Yes Sometimes No

9. Have you had any significant noise exposure during work, recreation or military service?

Yes Sometimes No

10. Have any of your relatives had a hearing loss?

Yes Sometimes No

Your Score: 0

Scores of 3 or more may mean that you have a hearing problem. Scores of 6 or more strongly suggest that a hearing check is warranted.

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