1. Is it difficult to follow a conversation in a noisy restaurant or crowded room? 1. Is it difficult to follow a conversation in a noisy restaurant or crowded room? Yes No

2. Does it sometimes feel that people are mumbling or not speaking clearly? 2. Does it sometimes feel that people are mumbling or not speaking clearly? Yes No

3. Is it difficult to follow dialog in the theater? 3. Is it difficult to follow dialog in the theater? Yes No

4. Is it difficult to understand a speaker at a public meeting or a religious service? 4. Is it difficult to understand a speaker at a public meeting or a religious service? Yes No

5. Do people need to speak up or repeat themselves? 5. Do people need to speak up or repeat themselves? Yes No

6. Are men’s voices easier to understand than women’s? 6. Are men’s voices easier to understand than women’s? Yes No

7. Is it difficult to understand soft or whispered speech? 7. Is it difficult to understand soft or whispered speech? Yes No

8. Is it difficult to understand the person on the other side of the telephone line? 8. Is it difficult to understand the person on the other side of the telephone line? Yes No

9. Does a hearing problem cause embarrassment when meeting new people? 9. Does a hearing problem cause embarrassment when meeting new people? Yes No

10. Does the hearing problem feel like a handicap? 10. Does the hearing problem feel like a handicap? Yes No

11. Does a hearing problem cause less visits to friends, relatives or neighbors than usual? 11. Does a hearing problem cause less visits to friends, relatives or neighbors than usual? Yes No

12. Is there ringing or noises in the ears? 12. Is there ringing or noises in the ears? Yes No

13. Does one ear hear better than the other? 13. Does one ear hear better than the other? Yes No

14. Is there significant noise exposure during work, recreation, or military service? 14. Is there significant noise exposure during work, recreation, or military service? Yes No

15. Have any relatives (by birth) had a hearing loss? 15. Have any relatives (by birth) had a hearing loss? Yes No