Hearing Questionnaire

Answer Yes or No to the following questions:

Are you over 40 years old?	Yes No
Do any of your relatives have hearing loss?	Yes No
Do you feel people are mumbling or whispering when they talk to you?	Yes No
Do you have difficulty hearing a speaker in meetings, at services, or at lectures?	Yes No
Do you difficulty watching movies or in a theatre?	Yes No
Are you finding yourself asking people to repeat or speak up?	Yes No
Do you find it easier to understand male speakers than female speakers?	Yes No
Do you have trouble hearing on the telephone?	Yes No
Are you embarrassed to be in social situations because of your hearing loss?	Yes No
Are you avoiding seeing friends, family or neighbors because you find it hard to hear them?	Yes No
Do you have ringing or buzzing noises in your ears?	Yes No
Do you currently, or have you ever worked or been exposed to significant loud noise?	Yes No

If you scored 2 or greater you are at risk for having a hearing loss.

If you scored 6 or higher you should have you hearing tested.