Hearing Handicap Questionnaire Form
Please complete this form to help assess your hearing experience in daily situations. Your responses will assist in understanding the challenges you may face.
How would you rate your overall hearing ability?
*
Excellent
Good
Fair
Poor
How often do you have difficulty hearing when talking with one person in a quiet room?
*
Never
Rarely
Sometimes
Often
Always
How often do you have difficulty following conversations in a group?
*
Never
Rarely
Sometimes
Often
Always
How often do you have trouble understanding speech in noisy environments (e.g., restaurants, crowded rooms)?
*
Never
Rarely
Sometimes
Often
Always
How often do you need to ask people to repeat themselves?
*
Never
Rarely
Sometimes
Often
Always
Please rate your level of difficulty hearing in the following situations:
*
Rows
Never
Rarely
Sometimes
Often
Always
Watching television
1
2
3
4
5
Speaking on the phone
6
7
8
9
10
Hearing doorbells or alarms
11
12
13
14
15
Listening to music or radio
16
17
18
19
20
How much does your hearing difficulty affect your daily life?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
How confident are you in your ability to communicate in most situations?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
How would you rate your satisfaction with your current hearing ability?
*
1
2
3
4
5
Is there anything else you would like to share about your hearing experience?
Submit
Should be Empty: