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Hearing Screening Questionnaire

Instructions

Please answer the following questions honestly. This self‑screening tool is not a diagnostic test but helps identify whether you may benefit from a professional hearing evaluation.

1. Everyday Communication
Do you often ask people to repeat themselves?
Do you find it difficult to follow conversations in noisy places (markets, weddings, traffic)?
Do family members complain that you keep the TV or mobile volume too high?
Do you struggle to hear children’s voices or high‑pitched sounds?
2. Ear Health & Symptoms
Do you experience ringing, buzzing, or humming in your ears (tinnitus)?
Do you suffer from frequent ear infections or discharge?
Do you feel pain, itching, or fullness in your ears?
Have you ever used sharp objects or home remedies to clean your ears?
3. Lifestyle & Environmental Factors
Are you regularly exposed to loud sounds (traffic horns, construction sites, factory noise, loudspeakers during festivals)?
Do you use headphones/earphones for long hours at high volume?
Do you smoke or consume alcohol frequently?
Do you take long‑term medications (e.g., TB drugs, chemotherapy, certain antibiotics) known to affect hearing?
4. Medical & Family History
Were you born with low birth weight, jaundice, or birth complications?
Did your mother have infections (e.g., rubella, measles, CMV) during pregnancy?
Do you have a family history of hearing loss?
Have you ever had head injury, meningitis, or high fever affecting the ears?
5. Age & Functional Impact
Are you above 50 years of age?
Do you avoid social gatherings because of difficulty hearing?
Do you feel isolated or frustrated due to communication problems?
Do you struggle to hear temple prayers, bhajans, or community events clearly?

Designed by Unicare Speech & Hearing Clinic 

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