Instructions: The purpose of this scale is to identify the problems a
hearing loss may be causing your friend or family member. Please select the
appropriate number ranging from 1 to 5 for the following questions. Select only
one number for each question. If the patient has a hearing aid, please fill out
the form according to how he/she communicates when the hearing aid is not
in use.
Various Communication
Situations:
(1) Does he/she experience communication difficulties in situations when
speaking with one other person? (for example, at home, at work, in a social
situation, with a waitress, a store clerk, with a spouse, boss, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(2) Does he/she experience
communication difficulties in situations when conversing with a small group of
several persons? (for example, with friends or families, co-workers, in meetings
or casual conversations, over dinner or while playing cards, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(3)
Does he/she experience communication difficulties while listening to someone
speak to a large group? (for example, at a church or civic meeting, in a
fraternal or women's club, at an educational lecture, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(4)
Does he/she experience communication difficulties while participating in various
types of entertainment? (for example, movies, TV, radio, plays, night clubs,
musical entertainment, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(5)
Does he/she experience communication difficulties when in an unfavorable
listening environment? (for example, at a noisy party, where there is background
music, when riding in an auto or bus, when someone whispers or talks from across
the room, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(6)
Does he/she experience communication difficulties when using or listening to
various communication devices? (for example, telephone, telephone ring,
doorbell, public address system, warning signals, alarms, etc.)
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
Feelings
About Communication:
(7)
Do you feel that any difficulty with his/her hearing limits or hampers his/her
personal or social life?
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(8)
Does any problem or difficulty with his/her hearing upset them?
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
Other
People:
(9)
Do you or others suggest that her/she has a hearing problem?
1) almost never (or never)
2) occasionally (about 1/4 of the time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
(10)
Do others leave him/her out of conversations or become annoyed because of
his/her hearing?
1) almost never (or never)
2) occasionally (about 1/4 of the
time)
3) about half of the time
4) frequently (about 3/4 of the time)
5) practically always (or always)
Scoring:
Add up all the points and refer to the scale listed below:
0 to 9 Count again the minimum score
possible on this test is 10
11 to 15 Any hearing loss you may have is only minor consult with
a hearing professional if you or a loved one questions these results.
16 to 25 You may have a mild to moderate hearing loss consult with a
professional for a complete audiological evaluation and possible
treatment.
26 to 35 You may have a moderate to severe hearing loss consult with a
hearing professional for a complete audiological evaluation and proper treatment.
36 to 45 You most probably have a severe hearing loss it is highly
advised you consult with hearing professional for a complete audiological
evaluation and proper treatment.
46 to 50 You have a severe to profound hearing loss. Consult immediately
with a hearing professional.
Over 51 Add again the maximum score possible is 50.
