Self Assessment

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Full Name*
Phone*
Email*
1. Do you feel like people are mumbling or talking softer than they used to?*
- Yes
- No
2. Do you feel like you can hear the voices but the exact words are not clear?*
- Yes
- No
3. When in background noise like at a restaurant, do you have trouble following the exact conversation?*
- Yes
- No
4. When in the company of others, are you easily distracted by background noise?*
- Yes
- No
5. Do you need the TV or radio louder than others at home?*
- Yes
- No
6. Do you have trouble hearing in the car – from the backseat or the indicator?*
- Yes
- No
7. Do you have trouble in meetings following exact conversations?*
- Yes
- No
8. Do you often get missed calls as you cannot hear the phone ring clearly?*
- Yes
- No
9. Do you have trouble if someone is quietly spoken or has an accent on the phone?*
- Yes
- No
10. Do you feel tired or annoyed at the end of a long conversation?*
- Yes
- No
11. Do you have tinnitus or ringing in the ears?*
- Yes
- No
12. Do loved ones or friends comment that you are not hearing them?*
- Yes
- No
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