Patient Assessment Tool--Hearing Assessment

Date: ________________ Name: _____________________________
Symptom Rarely
(Less than
monthly)
Sometimes
(At least
monthly)
Often
(At least
weekly)
Always
(At least
daily)
1) Does a hearing problem cause you to feel embarrassed when meeting new people? ___ ___ ___ ___
2) Does a hearing problem cause you to feel frustrated when talking to members of your family? ___ ___ ___ ___
3) Do you have difficulty hearing when someone whispers? ___ ___ ___ ___
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 religious services less often than you would like? ___ ___ ___ ___
7) Does a hearing problem cause you to have arguments with family members? ___ ___ ___ ___
8) Does a hearing problem cause you difficulty when listening to TV or radio? ___ ___ ___ ___
9) Do you feel that 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? ___ ___ ___ ___
Modified from the Hearing Handicap Inventory for the Elderly--Screening Version (HHIE-S)
Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. July 1983; 25:37.