YOUTH Sound Sensitivity Questionnaire - Soundwave Hearing Care

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YOUTH Sound Sensitivity Questionnaire

YOUTH Sound Sensitivity Questionnaire 2021

Client Name
Date
MM slash DD slash YYYY
Choose One
- Initial
- Follow Up
- Final
These questions are about EVERYDAY & ENVIRONMENTAL SOUNDS
1. Do you have trouble concentrating in a noisy or loud environment?
- Yes
- Sometimes
- No
2. Do you have trouble reading in a noisy or loud environment?
- Yes
- Sometimes
- No
3. 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
4. Do you find it harder to ignore sounds around you in everyday situations?
- Yes
- Sometimes
- No
5. Do you find it difficult to listen to speaker announcements (school, stores.)?
- Yes
- Sometimes
- No
6. Are you particularly sensitive to or bothered by street noise?
- Yes
- Sometimes
- No
7. Do you “automatically” cover your ears in the presence of somewhat louder sounds?
- Yes
- Sometimes
- No
8. When someone suggests doing something (movies, malls, restaurants) do you immediately think about the noise you are going to have to put up with?
- Yes
- Sometimes
- No
9. Do you ever turn down an invitation or not go out because of the noise you would have to face?
- Yes
- Sometimes
- No
10. Do you find the noise unpleasant in certain social situations (birthday parties, school assemblies, firework displays, big family get-togethers)?
- Yes
- Sometimes
- No
11. Has anyone you know ever told you that you tolerate noise or certain kinds of sounds badly?
- Yes
- Sometimes
- No
12. Are you particularly bothered by sounds others are not?
- Yes
- Sometimes
- No
13. Are you afraid of sounds that others are not?
- Yes
- Sometimes
- No
14. Do noise and certain sounds cause you stress and irritation?
- Yes
- Sometimes
- No
15. Are you less able to concentrate in noise toward the end of the day?
- Yes
- Sometimes
- No
16. Do stress and tiredness reduce your ability to concentrate in noise?
- Yes
- Sometimes
- No
17. Do you find sounds annoy you and not others?
- Yes
- Sometimes
- No
18. Are you emotionally drained by having to put up with all daily sounds?
- Yes
- Sometimes
- No
19. Do you find daily sounds having an emotional impact on you?
- Yes
- Sometimes
- No
20. Are you irritated by sounds others are not?
- Yes
- Sometimes
- No

YOUTH Sound Sensitivity Questionnaire 2021

These questions are about EVERYDAY & ENVIRONMENTAL SOUNDS

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