For each question, click on only one possible answer. If you already wear a hearing instrument, answer as though you were hearing without the hearing instrument.

Have you ever had the feeling that your hearing is bad?
	never
	seldom
	sometimes
	often
	always (nearly always)
Do you find it difficult to understand the individual words of a popular song when you hear it on the radio?
	never
	seldom
	sometimes
	often
	always (nearly always)
Is it difficult for you to understand a conversation when many people are in the same room?
	never
	seldom
	sometimes
	often
	always (nearly always)
Do you hear the telephone ringing when it's in another room?
	never
	seldom
	sometimes
	often
	always (nearly always)
Do you hear the telephone ringing when it's in the same room?
	never
	seldom
	sometimes
	often
	always (nearly always)
Are you sometimes disturbed while reading or learning by noises from the next room?
	never
	seldom
	sometimes
	often
	always (nearly always)
Do you hear water boiling when you're in the kitchen?
	never
	seldom
	sometimes
	often
	always (nearly always)
Can you understand a dinner conversation at the table well when several people are present?
	never
	seldom
	sometimes
	often
	always (nearly always)
On the whole, I would describe my hearing ability with the right ear as ...
	good
	satisfactory
	somewhat limited
	poor
	very poor
On the whole, I would describe my hearing ability with the left ear as ...
	good
	satisfactory
	somewhat limited
	poor
	very poor
On the whole, I would describe my hearing ability during conversations with several people as ...
	good
	satisfactory
	somewhat limited
	poor
	very poor
On the whole, I would describe my ability to recognize where a device (e.g. an alarm clock or a telephone) is from the noise which it makes as ...
	good
	satisfactory
	somewhat limited
	poor
	very poor
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