How to Tell You Might Have a Hearing Loss1 2 3 1. Do you find it difficult to follow a conversation in a noisy restaurant or crowded room?*YesNoSometimes2. Do you sometimes feel that people are mumbling or not speaking clearly?*YesNoSometimes3. Do you experience difficulty following dialog in the theater?*YesNoSometimes4. Do you sometimes find it difficult to understand a speaker at a public meeting or a religious service?*YesNoSometimes5. Do you find yourself asking people to speak up or repeat themselves?*YesNoSometimes 6. Do you find men's voices easier to understand than women's?*YesNoSometimes7. Do you experience difficulty under standing soft or whispered speech?*YesNoSometimes8. Do you have difficulty understanding speech on the telephone?*YesNoSometimes9. Does a hearing problem cause you to feel embarrassed when meeting new people?*YesNoSometimes 10. Do you feel handicapped by a hearing problem?*YesNoSometimes11. Does a hearing problem cause you to visit friends, relatives, or neighbors less often than you would like?*YesNoSometimes12. Do you experience ringing or noises in your ears?*YesNoSometimes13. Do you hear better with one ear than the other?*YesNoSometimes14. Have you had any significant noise exposure during work, recreation, or military service?*YesNoSometimes15. Have any of your relatives (by birth) had a hearing loss?*YesNoSometimesCAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.