01
♬
Do you have difficulty hearing when background noise is present?
YesNo
02
◌
Do you misunderstand what people are saying?
03
♙
Do you have difficulty hearing and/or understanding children?
04
◉
Do you have ringing in your ears?
05
♟
Do you have difficulty understanding speech in a group of people?
06
↻
Do you often ask that statements, questions or directions be repeated?
07
☏
Do you hear people speaking, but have difficulty understanding the words?
08
◖
Must others raise their voices or move closer to help you hear them?
09
▣
Do you turn the television up louder than normal to hear clearly?
10
Do you have to concentrate so much to listen that you tire from it?
11
?
Do you ever avoid a situation because you may not be able to hear well?
12
▱
Do you have difficulty understanding conversations in the car?
13
⌕
Do you have difficulty understanding conversations on the telephone?
Name
Email *