Hearing Inventory Questionnaire for Children

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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Child's Name

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

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

Sometimes

Yes

2. Does a hearing problem cause your child to feel embarrassed when they meet new

Sometimes

Yes

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

Sometimes

Yes

4. Does a hearing problem make your child irritable?

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

7. Does your child have difficulty hearing/understanding co-workers, clients/customers, or waitstaff?

Sometimes

Yes

8. Does your child feel significantly disadvantaged by a hearing problem?

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

12. Does a hearing problem cause your child to be nervous?

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

17. Does any problem or difficulty with your child’s hearing upset them at all?

Sometimes

Yes

18. Does a hearing problem cause your child to want to be by themselves?

Sometimes

Yes

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

Sometimes

Yes

20. Does your child feel that any difficulty with their hearing limits or hampers their personal or social life?

Sometimes

Yes

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

Sometimes

Yes

22. Does a hearing problem cause your child to feel depressed?

Sometimes

Yes

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

Sometimes

Yes

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

Sometimes

Yes

25. Does a hearing problem cause your child to feel left out when they 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.