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Please circle the answers that come closest to your everyday experience. Notice that each choice includes a percentage. You can use this to help you decide on your answer. For example, if the statement is true about 75% of the time, circle C for that item. If you have not experienced the situation we describe, try to think of a similar situation that you have been in and respond for that situation. If you have no idea, leave that item blank.

  • A Always (99%)
  • B Almost Always (87%)
  • C Generally (75%)
  • D Half-the-time (50%)
  • E Occasionally (25%)
  • F Seldom (12%)
  • G Never (1%)


For some items, an answer of “Always (99%)” indicates few problems. Other items are written so that an answer of “Always (99%)” indicates a lot of problems. Here is an example. In item (a), below, an answer of “Always (99%)” means that you often have problems. In item (b), below, the same answer means that you seldom have problems.

Without Hearing Aids With Hearing Aids
a. When I’m talking with a friend outdoors on a windy day, I miss a lot of the conversation.
b. When I am in a meeting with several other people, I can comprehend speech.

Please begin answering the questions

Without Hearing Aids With Hearing Aids
1 When I am in a crowded grocery store,talking with the cashier, I can follow the conversation.
2 I miss a lot of information when I am listening to a lecture.
3 Unexpected sounds, like a smoke detector or alarm bell are uncomfortable.
4 I have difficulty hearing a conversation when I am with one of my family at home.
5 I have trouble understanding the dialogue in a movie or at the theater.
6 When I am listening to the news on the car radio, and family members are talking, I have trouble hearing the news.
7 When I am at the dinner table with several people, and am trying to have a conversation with one person, understanding speech is difficult.
8 Traffic noises are too loud.
9 When I am talking with someone across a large empty room, I understand the words.
10 When I am in a small office, interviewing or answering questions, I have difficulty following the conversation.
11 When I am in a theater watching a movie or play, and the people around me are whispering and rustling paper wrappers, I can still make out the dialogue.
12 When I am having a quiet conversation with a friend, I have difficulty understanding.
13 The sounds of running water, such as a toilet or shower, are uncomfortably loud.
14 When a speaker is addressing a small group, and everyone is listening quietly, I have to strain to understand.
15 When I am in a quiet conversation with my doctor in an examination room, it is hard to follow the conversation.
16 I can understand conversations even when several people are talking.
17 The sounds of construction work are uncomfortably loud.
18 It is hard for me to understand what is being said at lectures or church services.
19 I can communicate with others when we are in a crowd.
20 The sound of a fire engine siren close by is so loud that I need to cover my ears.
21 I can follow the words of a sermon when listening to a religious service.
22 The sound of screeching tires is uncomfortably loud.
23 I have to ask people to repeat themselves in one-on-one conversation in a quiet room.
24 I have trouble understanding others when an air conditioner or fan is on.

Please fill out these additional items.



DEGREE OF HEARING DIFFICULTY (without wearing a hearing aid):