Questionnaire
Question | Yes | No | Sometimes |
| 1. Does a hearing problem cause you to feel embarassed when you meet new people? | 4 | 0 | 2 |
| 2. Does a hearing problem cause you to feel frustrated when talking to members of your family? | 4 | 0 | 2 |
| 3. Do you have difficulty hearing when someone speaks in a whisper? | 4 | 0 | 2 |
| 4. Do you feel handicapped by a hearing problem? | 4 | 0 | 2 |
| 5. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? | 4 | 0 | 2 |
| 6. Does a hearing problem cause you to attend religious services less often than you would like? | 4 | 0 | 2 |
| 7. Does a hearing problem cause you to have arguments with family members? | 4 | 0 | 2 |
| 8. Does a hearing problem cause you difficulty when listening to TV or radio? | 4 | 0 | 2 |
| 9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? | 4 | 0 | 2 |
| 10. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? | 4 | 0 | 2 |
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Scoring: Yes = 4 No = 0 Sometimes = 2 Total |
Interpretation of Total Score
0-8: 13% probability of hearing impairment
Schedule a baseline hearing evaluation
10-24: 50% probability of hearing impairment
Mild-moderate hearing handicap
Schedule an appointment for a diagnostic hearing evaluation
You may be a candidate for hearing help
26-40: 84% probability of hearing loss
Severe hearing handicap
Schedule an appointment for a diagnostic hearing evaluation and hearing aid evaluation
**Adapted from the Hearing Handicap Inventory for the Elderly-Screening Version
