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Adult Hyperacusis Questionnaire

ADULT HYPERACUSIS QUESTIONNAIRE

These questions are about EVERYDAY & ENVIRONMENTAL SOUNDS (not tinnitus)


Date
Year
Month
Day
Location for which you are filling the form
Form completed by
Self
Parent
Other
Do you have trouble concentrating in a noisy or loud environment?
Yes
Sometimes
No
Do you have trouble reading in a noisy or loud environment?
Yes
Sometimes
No
Do you ever use earplugs or earmuffs to reduce your noise perception? (Do not consider the use of hearing protection during abnormally high exposure situations.)
Yes
Sometimes
No
Do you find it harder to ignore sounds around you in everyday situations?
Yes
Sometimes
No
Do you find it difficult to listen to speaker announcements (such as airport, airplanes, trains, etc.)?
Yes
Sometimes
No
Are you particularly sensitive to or bothered by street noise?
Yes
Sometimes
No
Do you “automatically” cover your ears in the presence of somewhat louder sounds?
Yes
Sometimes
No
When someone suggests doing something (going out, to the cinema, to a concert, etc.), do you immediately think about the noise you are going to have to put up with?
Yes
Sometimes
No
Do you ever turn down an invitation or not go out because of the noise you would have to face?
Yes
Sometimes
No
Do you find the noise unpleasant in certain social situations (e.g., nightclubs, pubs or bars, concerts, firework displays, cocktail receptions)?
Yes
Sometimes
No
Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly?
Yes
Sometimes
No
Are you particularly bothered by sounds others are not?
Yes
Sometimes
No
Are you afraid of sounds that others are not?
Yes
Sometimes
No
Do noise and certain sounds cause you stress and irritation?
Yes
Sometimes
No
Are you less able to concentrate in noise toward the end of the day?
Yes
Sometimes
No
Do stress and tiredness reduce your ability to concentrate in noise?
Yes
Sometimes
No
Do you find sounds annoy you and not others?
Yes
Sometimes
No
Are you emotionally drained by having to put up with all daily sounds?
Yes
Sometimes
No
Do you find daily sounds have an emotional impact on you?
Yes
Sometimes
No
Are you irritated by sounds others are not?
Yes
Sometimes
No
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Calgary, AB,
T2E 7C5, Canada

Phone: 403-270-7425
Toll free: 1-866-402-5552

info@soundwavehearing.com

Monday - Thursday
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Closed noon - 1:00 PM

Friday 8:00 AM - 1:00 PM

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High River, AB,
T1V 1M3, Canada
Phone: 403-652-7721

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Monday - Thursday:
9:00 AM - 4:30 PM

Friday: Closed

(Closed everyday 12.30 PM - 1 PM for lunch)

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#102 10712 100 Street,
Grande Prairie, AB,
T8V 3X8, Canada

Phone: 780-538-2744
Toll free: 1-877-402-7771

info@soundwavehearing.com

 

Monday - Thursday
8:00 AM - 5:00 PM

Closed noon - 1:00 PM

Friday 8:00 AM - 1:00 PM

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Lethbridge, AB,
T1J 0J9, Canada

Toll free: 1-866-402-5552

info@soundwavehearing.com

 

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