Paediatric Audiology Questionnaire

PAEDIATRIC AUDIOLOGY
SELF ASSESSMENT OF COMMUNICATION-ADOLESCENT (SAC-A)* questionnaire
ID number*
This will be provided by the Audiologist
The purpose of this questionnaire is to identify problems you may be having because of your hearing loss. We will talk about your answers.That conversation may help us understand the effect the hearing loss is having on you. It may also give us ideas to help you manage those problems.
Please select the most appropriate answer for each of the following questions. Select only one answer for each question. If you usually use hearing aids answer each question in a way that describes your experiences with the technology on. If you do not usually use hearing aids, answer each question in a way that describes your experiences without the technology.

Hearing and understanding at different times*

	Almost never	Occasionally	About half the time	Frequently	Almost always
Is it hard for you to hear or understand when talking with only one other person?
Is it hard for you to hear or understand when talking with a group of people?
Is it hard for you to hear or understand the TV, the radio or CDs?
Is it hard for you to hear or understand if there is noise or music in the background, or other people are talking at the same time?
Is it hard for you to hear or understand in your classes?
Do you hear better when using your hearing aids?

Feelings about communication

	Almost never	Occasionally	About half the time	Frequently	Almost always
Do you feel left out of conversations because it’s hard to hear?
Does anything about your hearing loss upset you?
Do you feel different from other kids when you are wearing your hearing aids or cochlear implants?

Other people

	Almost never	Occasionally	About half the time	Frequently	Almost always
Do strangers or people you don’t know well notice that you have a hearing loss?
Do other people become frustrated when they talk to you because of your hearing loss?
Do people treat you differently when you wear your hearing aids?

PAEDIATRIC AUDIOLOGY