Instructions: Select No, Sometimes, or Yes in response to each question. If you do not participate in a particular activity, respond according to the way you feel you would respond in that situation.
Does a hearing problem cause you to feel embarrassed when you meet new people? No Sometimes Yes
Does a hearing problem cause you to feel frustrated when talking to members of your family? No Sometimes Yes
Do you have difficulty hearing when someone speaks in a whisper? No Sometimes Yes
Do you feel handicapped by a hearing problem? No Sometimes Yes
Does a hearing problem cause you difficulty when visiting friends, relatives or neighbours? No Sometimes Yes
Does a hearing problem cause you to attend meetings or religious services less often than you would like? No Sometimes Yes
Does a hearing problem cause you to have arguments with family members? No Sometimes Yes
Does a hearing problem cause you difficulty when listening to TV or radio? No Sometimes Yes
Do you feel that any difficulty with your hearing limits or hampers your personal or social life? No Sometimes Yes
Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? No Sometimes Yes
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