HEARING HANDICAP INVENTORY FOR THE ELDERLY SCREENING (HHIE-S) NAME: DOB: DATE: YES NO 1. Are you having hearing problems? Instructions: If you respond YES then please answer the further follow-up questions below. YES SOMETIMES NO (4 points) (2 points) (0 points) 1. Does a hearing problem cause you to feel embarrassed 4 2 0 when meeting new people? 2. Does a hearing problem cause you to feel frustrated when 4 2 0 talking to members of your family? 3. Do you have difficulty hearing when someone speaks in a 4 2 0 whisper? 4. Do you feel handicapped by a hearing problem? 4 2 0 Does a hearing problem cause you difficulty when visiting 5. 4 2 0 friends, relatives, or neighbors? 6. Does a hearing problem cause you to attend religious 4 2 0 services less often than you would like? 7. Does a hearing problem cause you to have arguments with 4 2 0 family members? 8. Does a hearing problem cause you difficulty when listening 4 2 0 to TV or radio? 9. Do you feel that any difficulty with your hearing limits or 4 2 0 hampers your personal or social life? 10. Does a hearing problem cause you difficulty when in a 4 2 0 restaurant with relatives or friends? Add column answers together = TOTAL: _____________ Interpretation of Score: 0-8 suggests no hearing handicap 10-24 suggests mild-moderate hearing handicap, consider referral 16-40 suggests significant hearing handicap, consider referral
HEARING HANDICAP INVENTORY FOR THE ELDERLY SCREENING (HHIE-S) NAME: DOB: DATE: YES NO 1. Are you having hearing problems? Instructions: If you respond YES then please answer the further follow-up questions below. YES (4 points) SOMETIMES (2 points) NO (0 points) 1. Does a hearing problem cause you to feel embarrassed when meeting new people? 4 2 0 2. Does a hearing problem cause you to feel frustrated when talking to members of your family? 4 2 0 3. Do you have difficulty hearing when someone speaks in a whisper? 4 2 0 4. Do you feel handicapped by a hearing problem? 4 2 0 5. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? 4 2 0 6. Does a hearing problem cause you to attend religious services less often than you would like? 4 2 0 7. Does a hearing problem cause you to have arguments with family members? 4 2 0 8. Does a hearing problem cause you difficulty when listening to TV or radio? 4 2 0 9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? 4 2 0 10. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? 4 2 0 Add column answers together = TOTAL: _____________ Interpretation of Score: 0-8 suggests no hearing handicap 10-24 suggests mild-moderate hearing handicap, consider referral 16-40 suggests significant hearing handicap, consider referral