Hear San Diego HomepageRegardless of your age, this inventory is quite useful in learning more about your hearing loss. You may be asked to complete this form at the time of your appointment with Dr. Bryan. Save yourself time in the office by completing this form or reviewing it, prior to your appointment.
ITEM |
YES (4 pts) |
SOMETIMES (2 pts) |
NO (0 pts) |
| Does a hearing problem cause you to feel embarrassed when you meet 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 speaks in a whisper? | |||
| 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 any difficulty with 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? | |||
| RAW SCORE ________ (sum of the points assigned each of the items) | |||
| INTERPRETING THE RAW SCORE 0 to 8 = 13% probability of hearing impairment (no handicap/no referral) 10 to 24 = 50% probability of hearing impairment (mild-moderate handicap/refer) 26 to 40 = 84% probability of hearing impairment (severe handicap/refer) | |||
| Source: Ventry, I, Weinstein B. (1983). Identification of elderly people with hearing problems. ©American Speech-Language-Hearing Association, July, 37-42. | |||