Instructions: The purpose of this scale is to identify the problems your
hearing loss may be causing you. Please select the appropriate number ranging
from 1 to 5 for the following questions. Select only one number for each
question. If you have a hearing aid, please fill out the form according to how
you communicate when the hearing aid is not
in use.
Various Communication
Situations:
(1) Do you 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)
Do you 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)
Do you 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)
Do you 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)
Do you experience communication difficulties when you are 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)
Do you 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 your hearing limits or hampers your
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 your hearing upset you?
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 others suggest that you have 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 you out of conversations or become annoyed because of your
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.
