Welcome to SIMS Hospital - Audiology Test Full Name Email Phone / Mobile No 1. Do you find it difficult to follow a conversation in a noisy restaurant or crowded room? Yes No Sometimes None 2. Do you sometimes feel that people are mumbling or not speaking clearly? Yes No Sometimes None 3. Do you experience difficulty following dialog in the theater? Yes No Sometimes None 4. Do you sometimes find it difficult to understand a speaker at a public meeting or a religious service? Yes No Sometimes None 5. Do you find yourself asking people to speak up or repeat themselves? Yes No Sometimes None 6. Do you find men’s voices easier to understand than women’s? Yes No Sometimes None 7. Do you experience difficulty understanding soft or whispered speech? Yes No Sometimes None 8. Do you have difficulty understanding speech on the telephone? Yes No Sometimes None 9. Does a hearing problem cause you to feel embarrassed when meeting new people? Yes No Sometimes None 10. Do you feel handicapped by a hearing problem? Yes No Sometimes None 11. Does a hearing problem cause you to visit friends, relatives, or neighbors less often than you would like? Yes No Sometimes None 12. Do you experience ringing or noises in your ears? Yes No Sometimes None 13. Do you hear better with one ear than the other? Yes No Sometimes None 14. Have any of your relatives (by birth) had a hearing loss? Yes No Sometimes None 15. Have you had any significant noise exposure during work, recreation, or military service? Yes No Sometimes None Time's up