First and Last Name:  * Email Address: Phone Number:  * Do you have difficulty understanding a conversation in a noisy restaurant or crowded room? Yes No Do you sometimes feel people are mumbling or not speaking clearly? YesNo Do you find it difficult to understand a speaker at a public meeting or religious service? YesNo Do you sometimes find yourself asking people to repeat or speak up? YesNo Do you have difficulty understanding speech or words on the telephone? YesNo Does a hearing problem cause you to visit with or talk with friends and relatives less often? YesNo Do you experience ringing or noises in your ears? YesNo Do you hear better with one ear than you do with the other? YesNo Have you had significant noise exposure at work recreational activities or in military service? YesNo Do you find male voices easier to understand than female voices? YesNo Do not enter anything in this field: