Hearing Checklist

Mark an X in the box that best describes how often you experience the following problems.

Symptom Rarely
(Less than
monthly)
Sometimes
(At least
monthly)
Often
(At least
weekly)
Always
(At least
daily)

Does a hearing problem cause you to feel embarrassed when meeting new people?

       

Does a hearing problem cause you to feel frustrated when talking to members of your family?

       

Do you have difficulty hearing when someone whispers?

       

Do you feel handicapped by a hearing problem?

       

Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

       

Does a hearing problem cause you to attend religious services less often than you would like?

       

Does a hearing problem cause you to have arguments with family members?

       

Does a hearing problem cause you difficulty when listening to TV or radio?

       

Do you feel that your hearing limits or hampers your personal or social life?

       

Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

       

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.