Hearing Inventory Questionnaire for Adults

Please complete the following prior to your appointment

Please fill in your details below:

First Name*

Last Name

Email*

Contact Number*

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Please answer No, Sometimes, or Yes for each question. Do not skip a question if you avoid a situation because of a hearing problem.

1. Does a hearing problem cause you to use the phone less often than you would like?

Sometimes

Yes

2. Does a hearing problem cause you to feel embarrassed when you meet new people?

Sometimes

Yes

3. Does a hearing problem cause you to avoid groups of people?

Sometimes

Yes

4. Does a hearing problem make you irritable?

Sometimes

Yes

5. Does a hearing problem cause you to feel frustrated when talking to members of your family?

Sometimes

Yes

6. Does a hearing problem cause you difficulty when attending a party?

Sometimes

Yes

7. Do you have difficulty hearing/understanding co-workers, clients/customers, or waitstaff?

Sometimes

Yes

8. Do you feel significantly disadvantaged by a hearing problem?

Sometimes

Yes

9. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

Sometimes

Yes

10. Does a hearing problem cause you to feel frustrated with hearing/understanding co-workers, clients/customers, or waitstaff?

Sometimes

Yes

11. Does a hearing problem cause you difficulty hearing in the movies or in the theatre?

Sometimes

Yes

12. Does a hearing problem cause you to be nervous?

Sometimes

Yes

13. Does a hearing problem cause you to visit friends, relatives, or neighbors less often than you would like?

Sometimes

Yes

14. Does a hearing problem cause you to have arguments with family members?

Sometimes

Yes

15. Does a hearing problem cause you difficulty when listening to TV or radio?

Sometimes

Yes

16. Does a hearing problem cause you to go shopping less often than you would like?

Sometimes

Yes

17. Does any problem or difficulty with your hearing upset you at all?

Sometimes

Yes

18. Does a hearing problem cause you to want to be by yourself?

Sometimes

Yes

19. Does a hearing problem cause you to talk to family members less often than they would like?

Sometimes

Yes

20. Do you feel that any difficulty with your hearing limits or hampers your personal or social life?

Sometimes

Yes

21. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

Sometimes

Yes

22. Does a hearing problem cause you to feel depressed?

Sometimes

Yes

23. Does a hearing problem cause you to listen to the television or the radio less often than they would like?

Sometimes

Yes

24. Does a hearing problem cause you to feel uncomfortable when talking to friends?

Sometimes

Yes

25. Does a hearing problem cause you to feel left out when you are with a group of people?

Sometimes

Yes

Audiologist to complete

Totals: __________

Grand Total: __________

Reference: Newman, C. W., Weinstein, B. E., Jacobson, G. P., & Hug, G. A. (1990). The Hearing
Handicap Inventory for Adults: psychometric adequacy and audiometric correlates. Ear and
Hearing, 11, 430–433.