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Significant Other Assessment of Communication

Instructions:

The purpose of this scale is to identify the problems a hearing loss may be causing your Significant Other.

Please select the appropriate number ranging from 1 to 5 for the following questions.
Select only one number for each question.

If the patient has a hearing aid, please fill out the form according to how he/she communicates when the hearing aid is not in use.

Please answer the following questions
before filling out the hearing handicap scale:

Age of Significant Other in years

Sex of Significant Other

Do you feel like your Significant Other has a hearing loss and if you do, how often does it cause problems in educational, social, or occupational activities?

Has s/he had a hearing test within the last two years, and if so what was the result of this test?

Please enter your email address.

Would you like your results emailed to you?

Various Communication Situations:

(1) Does he/she experience communication difficulties in situations when speaking with one other person? (for example, at home, at work, in a social situation, with a waitress, a store clerk, with a spouse, boss, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(2) Does he/she experience communication difficulties in situations when conversing with a small group of several persons? (for example, with friends or families, co-workers, in meetings or casual conversations, over dinner or while playing cards, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(3) Does he/she experience communication difficulties while listening to someone speak to a large group? (for example, at a church or civic meeting, in a fraternal or women's club, at an educational lecture, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(4) Does he/she experience communication difficulties while participating in various types of entertainment? (for example, movies, TV, radio, plays, night clubs, musical entertainment, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(5) Does he/she experience communication difficulties when you are in an unfavorable listening environment? (for example, at a noisy party, where there is background music, when riding in an auto or bus, when someone whispers or talks from across the room, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(6) Does he/she experience communication difficulties when using or listening to various communication devices? (for example, telephone, telephone ring, doorbell, public address system, warning signals, alarms, etc.) 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
Feelings About Communication: (7) Do you feel that any difficulty with his/her hearing limits or hampers his/her personal or social life? 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
8) Does any problem or difficulty with his/her hearing upset them? 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
Other People: (9) Do you or others suggest that her/she has a hearing problem? 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)
(10) Do others leave him/her out of conversations or become annoyed because of his/her hearing? 1) almost never (or never) 2) occasionally (about 1/4 of the time) 3) about half of the time 4) frequently (about 3/4 of the time) 5) practically always (or always)

Remember to answer all of the questions and if he/she wears a hearing aid answer the way they hear without the hearing aid.

* Reprinted with permission from Ventry, I. & Weinstein, B. The Hearing Handicap Inventory for the Elderly: A new tool. Ear Hear., 3, 128-134 (1982)