1. Do you have difficulty hearing when background noise is present? Yes No 2. Do you misunderstand what people are saying? Yes No 3. Do you have difficulty hearing and/or understanding children? Yes No 4. Do you have ringing in your ears? Yes No 5. Do you have difficulty understanding speech in a group of people? Yes No 6. Do you often ask that statements, questions or directions be repeated? Yes No 7. Do you hear people speaking, but have difficulty understanding the words? Yes No 8. Must others raise their voices or move closer to help you hear them? Yes No 9. Do you turn the television up louder than normal to hear clearly? Yes No 10. Do you have to concentrate so much to listen that you tire from it? Yes No 11. Do you ever avoid a situation because you may not be able to hear well? Yes No 12. Do you have difficulty understanding conversations in the car? Yes No 13. Do you have difficulty understanding conversations on the telephone? Yes No First Name Last Name Email Address Phone Number