Hearing Survey | Northern Hearing Services

Name *

Phone *

Email *

1. I have a problem hearing over the phone.

yesno

2. I have trouble following the conversation when two or more people are talking at the same time.

yesno

3. People complain that I turn the TV volume too high.

yesno

4. I have to strain to understand conversations.

yesno

5. I have trouble hearing conversations in a noisy background such as a party.

yesno

6. I miss hearing some common sounds like the phone or doorbell ring.

yesno

7. I get confused about where sounds come from.

yesno

8. I misunderstand some words in a sentence and need to ask people to repeat themselves.

yesno

9. I especially have trouble understanding the speech of women and children.

yesno

10. I have worked in noisy environments.

yesno

11. Many people mumble when they talk.

yesno

12. People get annoyed because I misunderstand what is being said.

yesno

13. I misunderstand what others are saying and make inappropriate responses.

yesno

14. I avoid social activities because I cannot hear well and fear that I'll reply improperly.

yesno