Hearing Loss Questionnaire - Printable
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Hearing Loss Questionnaire
(Weinstein, 1992)
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QUESTIONS
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YES
Four (4) Points
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NO
Zero (0) Points
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SOMETIMES
Two (2) Points
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| 1. Does a hearing problem cause you to feel embarrassed when meeting new people? |
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| 2. Does a hearing problem cause you to feel frustrated when talking to members of your family? |
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| 3. Do you have difficulty hearing when someone speaks in a whisper? |
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| 4. Do you feel handicapped by a hearing problem? |
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| 5. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? |
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| 6. Does a hearing problem cause you to attend religious services less often than you would like? |
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| 7. Does a hearing problem cause you to have arguments with family members? |
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| 8. Does a hearing problem cause you difficulty when listening to TV or radio? |
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| 9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? |
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| 10. Does a hearing problem cause you difficulty when in a restaurant with relatives and friends? |
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| TOTAL OF ALL COLUMNS |
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0-10 = no handicap; 11-26 = mild to moderate handicap; 27-40 = significant handicap
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