Functional Hearing Assessment Checklist Form
Evaluate functional hearing abilities and communication challenges in daily situations.
How often do you have difficulty understanding speech in a quiet room?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How often do you struggle to follow conversations in noisy environments (e.g., restaurants, parties)?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Do you have difficulty hearing on the telephone?
*
Never
Sometimes
Often
Always
Do you ask others to repeat themselves during conversations?
*
Never
Rarely
Sometimes
Frequently
Rate your ability to localize (find the direction of) sounds.
*
1
2
3
4
5
How well do you understand speech when more than one person is talking?
*
Very Poorly
1
2
3
4
Very Well
5
1 is Very Poorly, 5 is Very Well
How often do you avoid social situations because of hearing difficulties?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Checklist: In which situations do you experience hearing difficulties? (Check all that apply.)
*
Watching television
Group conversations
Talking with children
Public announcements
Outdoors
Other
Please indicate the degree of difficulty you experience in the following situations:
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Listening to music
1
2
3
4
Understanding speech from a distance
5
6
7
8
Following conversation in a car
9
10
11
12
Hearing doorbells or alarms
13
14
15
16
Do you currently use any assistive listening devices (e.g., hearing aids, FM systems)?
*
Yes, regularly
Yes, occasionally
No
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