Question	Yes (4 points)	Sometimes (2 points)	No (0 points)
Does a hearing problem cause you to feel embarrassed when you meet new people?	_____	_____	______
Does a hearing problem cause you to feel frustrated when talking to members of your family?	______	______	______
Do you have difficulty hearing when someone speaks in a whisper?	______	______	______
Do you feel impaired by a hearing problem?	______	______	______
Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?	______	______	______
Does a hearing problem cause you to attend religious services less often than you would like?	______	______	______
Does a hearing problem cause you to have arguments with family members?	______	______	______
Does a hearing problem cause you difficulty when listening to the television or radio?	______	______	______
Do you feel that any difficulty with your hearing limits or hampers your personal or social life?	______	______	______
Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?	______	______	______
Raw score (sum of the points assigned to each of the items)	______