Communications Assessment

How does your hearing loss affect the following situations?

Choose one of the ratings for each situation:

1. Always a problem (75–100% of the time)
2. Often a problem (50–75% of the time)
3. Sometimes difficult (25–50% of the time)
4. Never a problem (0–25% of the time)

______ Conversation with one person
______ Small group listening
______ Listening outdoors
______ Large group listening
______ At a concert/movie
______ In a place of worship
______ Watching TV
______ In a restaurant
______ Riding in a car/bus
______ On the telephone
______ On the cell phone (digital)
______ Listening to music
______ Listening at work
______ Leisure activities
______ Tell direction of sounds
______ Children’s voice
______ Family dinner
______ Others(list)

If you currently wear or own hearing aids, please rate the sound quality.

Choose one of the ratings for each situation:

1. Poor performance
2. Average performance
3. Good performance
4. Excellent performance

______ Clearness of sounds
______ Naturalness of own voice
______ Natural sounding
______ Hearing soft sounds
______ Comfort with loud sounds
______ Circuit/ambient noise

To schedule an appointment with a specialist at Main Line Health, call 484.227.3200 or use our secure online appointment request form.