Name *

First Name

Last Name

Do people seem to mumble or speak in a softer voice more than they use to? *

Yes

No

Do you feel tired or irritable after a long conversation? *

Yes

No

Do you sometimes miss keywords in a sentence? *

Yes

No

Do you frequently need to ask people to repeat themselves? *

Yes

No

Do you have difficulty understanding the conversation in a crowded room? *

Yes

No

Do you often turn the volume up on the TV or radio? *

Yes

No

Does background noise bother you? *

Yes

No

Is it sometimes hard to hear the conversation on the telephone? *

Yes

No

Do you sometimes not hear the doorbell or telephone ring? *

Yes

No

Are your family and/or friends complaining to you about your hearing? *

Yes

No