Do you have a problem hearing over the telephone?
Yes No

Do you have trouble following the conversation when two or more people are talking at the same time?
Yes No

Do people complain that you turn the TV volume up too high?
Yes No

Do you have to strain to understand conversation?
Yes No

Do you have trouble hearing in a noisy background?
Yes No

Do you find yourself asking people to repeat themselves?
Yes No

Do many people you talk to seem to mumble (or not speak clearly)?
Yes No

Do you misunderstand what others are saying and respond inappropriately?
Yes No

Do you have trouble understanding the speech of women and children?
Yes No

Do people get annoyed because you misunderstand what they say?
Yes No