___ 1. Does a hearing problem cause you to feel embarrassed when you meet new people? ___ 2. Does a heairng problem cause you to feel frustrated when talking to members of your family? ___ 3. Do you have difficulty hearing when someone speaks in a whisper? ___ 4. Do you feel handicapped by a hearing problem? ___ 5. Does a hearing problem cause you difficulty when visiting friends, relatives or neighbors? ___ 6. Does a hearing problem cause you to attend social gatherings or religious services less than you would like? ___ 7. Does a heairng problem cause you to have arugments with family members? ___ 8. Does a hearing problem cause you difficulty when listening to TV or radio? ___ 9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? ___ 10. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?
___ Total Score
0-8 No Handicap 10-24 Mild-Moderate Handicap 26-40 Severe Handicap