Assessment By Companion

Patient's Name

Today's Date

Your Name & Relationship to the Patient

Hearing assessment by the companion

Does your friend/family member find it difficult to follow a conversation in a noisy or crowded room?

Yes

No

Does your friend/family member feel that people are mumbling or not speaking clearly?

Yes

No

Does your friend/family member experience difficulty following dialog in the theater?

Yes

No

Does your friend/family member find it difficult to understand a speaker at a public meeting or a religious service?

Yes

No

Does your friend/family member find him/her self asking people to speak up or repeat themselves?

Yes

No

Does your friend/family member find men's voices easier to understand than voices of women or children?

Yes

No

Does your friend/family member experience difficulty understanding soft or whispered speech?

Yes

No

Does your friend/family member have difficulty understanding speech on the phone?

Yes

No

Does your friend/family member attend work or social meetings where he/she needs to be able to communicate amidst group conversation?

Yes

No

Does your friend/family member spend time in loud environments (sporting events, concerts, live theater) where he/she needs to hear in the presence of background noise?

Yes

No

Does difficulty with hearing cause your friend/family member to visit friends, relatives or neighbors less often than he/she would like?

Yes

No

Does your friend/family member experience ringing or noises in his/her ears?

Yes

No

Is your friend/family member actively working or need to communicate with people throughout the day?

Yes

No

Listening Environment Rating

Please provide the top three listening situations where you would like your friend/family member to hear better.

#1

#2

#3

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