Online Hearing Screener The following hearing loss check is a means of quickly assessing if you possibly have a hearing loss requiring referral for an objective hearing test and possible hearing solution. Name Name * Email Address * Phone Number * 1. Do you have trouble hearing clearly? Yes No 2. Are you missing conversations? Yes No 3. Do people mumble or are they unclear? Yes No 4. Do you have to ask people to repeat themselves often? Yes No 5. Does your spouse/loved ones tell you that the TV is too loud? Yes No 6, Do you have trouble hearing your friends in a restaurant? Yes No 7. Are phone conversations difficult? Yes No 8. Is it true that you don’t enjoy socializing with friends as much as you used to? Yes No 9. At the worst, does your hearing loss prevent you from enjoying your hobbies? Yes No 10. If you answered yes to #9 are you frustrated by this? Yes No 11. Is your hearing loss affecting your relationships with family or friends? Yes No 12. Do you get frustrated, and as a result avoid social contact or communication with family/friends? Yes No 13. Do you have trouble communicating with your grandchildren/great grandchildren? Yes No 14. Do you miss a lot of information when you are listening to a lecture? Yes No 15. Are traffic noises too loud? Yes No
