FHsportsmed-hearing-loss-pre-assessment

I have a problem hearing over the phone*

Almost Always Half the Time Occasionally Never

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

Almost Always Half the Time Occasionally Never

People complain that I turn the TV volume too high*

Almost Always Half the Time Occasionally Never

I have to strain to understand conversations*

Almost Always Half the Time Occasionally Never

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

Almost Always Half the Time Occasionally Never

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

Almost Always Half the Time Occasionally Never

I get confused about where sounds come from*

Almost Always Half the Time Occasionally Never

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

Almost Always Half the Time Occasionally Never

I especially have trouble understanding the speech of women and children*

Almost Always Half the Time Occasionally Never

I have worked in noisy environments*

Almost Always Half the Time Occasionally Never

Many people mumble when they talk*

Almost Always Half the Time Occasionally Never

People get annoyed because I misunderstand what is being said*

Almost Always Half the Time Occasionally Never

I misunderstand what others are saying and make inappropriate responses*

Almost Always Half the Time Occasionally Never

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

Almost Always Half the Time Occasionally Never

Do you think this person has a hearing loss? (to be answered by a family member):*

Yes No

Do you have a blood relative with hearing loss?(to be answered by a family member):*

Yes No

Name*

First Name

Last Name

Email*