A National Hearing Healthcare Benefit Program

Infants identified with hearing loss

can be fit with amplification by as young as 4 weeks of age. With appropriate early intervention, children with hearing loss can be mainstreamed in regular elementary and secondary education classrooms.

Better Hearing Check

Subjective Questionnaire With Results

The following hearing loss test is based on the Revised American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) five-minute hearing check.* It is a means of quickly assessing if you possibly have a hearing loss requiring referral for an objective hearing test and possible hearing solution. This test is related to objective measures of hearing loss using audiological equipment. Answer the questions related to your hearing. After submitting the form, you will be scored and be able to compare yourself to 2,304 adults with hearing loss.

Instructions

With respect to your hearing please think about your experiences with each of the following WITHOUT the use of hearing aids or other devices designed to help you hear better. For each item, indicate the degree to which you agree or disagree (circle one number for each item).

Step 1 - Better Hearing Check Questionaire

Name:
Email:
Year of Birth:

Question		Strongly AgreeDo Not Agree
1.	I have trouble hearing conversation in a noisy background such as a crowed room or restaurant.	1	2	3	4	5
2.	I have trouble following the conversation when two or more people are talking at the same time.	1	2	3	4	5
3.	I misunderstand what others are saying and make inappropriate responses.	1	2	3	4	5
4.	I have to strain to understand conversations	1	2	3	4	5
5.	I avoid social activities because I cannot hear well and fear I will reply improperly.	1	2	3	4	5
6.	Family members and friends have told me they think I may have a hearing loss.	1	2	3	4	5
7.	People get annoyed because I misunderstand what they say.	1	2	3	4	5
8.	I get confused about where sounds come from.	1	2	3	4	5
9.	I misunderstand some words in a sentence and need to ask people to repeat themselves.	1	2	3	4	5
10.	I have to worry about missing a telephone ring or doorbell	1	2	3	4	5
11.	I have a problem hearing over the telephone	1	2	3	4	5
12.	I have trouble understanding the speaker in a large room such as at a meeting or place of worship.	1	2	3	4	5
13.	Many people I talk to seem to mumble (or don't speak clearly.)	1	2	3	4	5
14.	I especially have trouble understanding the speech of women and children.	1	2	3	4	5
15.	I have trouble understanding things on TV	1	2	3	4	5

Infants identified with hearing loss

Better Hearing Check

Subjective Questionnaire With Results

Step 1 - Better Hearing Check Questionaire