| Please respond by circling the appropriate number
ranging from 1 to 5, for the following questions. If you have a
hearing aid, please fill out the form according to how you
communicate when aid is not in use.
|
| 1 = almost never (or never); 2 = occasionally (about one-quarter of the time); 3 = about half
of the time; 4 = frequently (about three-quarters of the time); 5 = practically always
(or always).
|
| Various Communication Situations |
| 1. Do you experience communication difficulties in
situations when speaking with one other person? (For example: at
home, at work, in a social situation, with a waitress, a store
clerk, a boss, etc.)
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|
1
|
2
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3
|
4
|
5
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| 2. Do you experience communication difficulties in
situations when conversing with a small group of several
persons? (For example: with friends or family, co-workers, in
meetings or casual conversations, over dinner, or while playing
cards, etc.).
|
|
1
|
2
|
3
|
4
|
5
|
| 3. Do you experience communication difficulties
while listening to someone speak to a large group? (For example,
at church or in a civic meeting, in a fraternal or
women's club, at an educational lecture, etc.)
|
|
1
|
2
|
3
|
4
|
5
|
| 4. Do you experience communication difficulties
while participating in various types of entertainment? (For
example: TV, radio, plays, night clubs, musical entertainment,
etc.)
|
|
1
|
2
|
3
|
4
|
5
|
| 5. Do you experience communication difficulties when
you are in an unfavorable listening environment? (For example:
at a noisy party, where there is background music, when riding
in an auto or a bus, when someone whispers or talks from across
the room, etc.)
|
|
1
|
2
|
3
|
4
|
5
|
| 6. Do you experience communication difficulties when
using or listening to various communication devices? (For
example: telephone, telephone ring, doorbell, public address
system, warning signals, alarms, etc.)
|
|
1
|
2
|
3
|
4
|
5
|
| Feelings About Communication |
| 7. Do you feel that any difficulty with your hearing
limits or hampers your personal or social life?
|
|
1
|
2
|
3
|
4
|
5
|
| 8. Does any problem or difficulty with your hearing
upset you?
|
|
1
|
2
|
3
|
4
|
5
|
| Other People |
| 9. Do others suggest that you have a hearing
problem?
|
|
1
|
2
|
3
|
4
|
5
|
| 10. Do others leave you out of conversations or
become annoyed because of your hearing?
|
|
1
|
2
|
3
|
4
|
5
|