Your name :

1. Speech Spatial Qualities Advice about answering the questions Please answer the following questions, then go on to the questions about your hearing The following questions inquire about aspects of your ability and experience hearing and listening in different situations. For each question, put a mark, such as a cross (x), anywhere on the scale shown against each question that runs from 0 through to 10. Putting a mark at 10 means that you would be perfectly able to do or experience what is described in the question. Putting a mark at 0 means you would be quite unable to do or experience what is described. As an example, question 1 asks about having a conversation with someone while the TV is on at the same time. If you are well able to do this then put a mark up toward the right-hand end of the scale. If you could follow about half the conversation in this situation put the mark around the mid-point, and so on. We expect that all the questions are relevant to your everyday experience, but if a question describes a situation that does not apply to you, put a cross in the “not applicable” box. Please also write a note next to that question explaining why it does not apply in your case. Your name : Today’s date : Your age: Please check one of these options: I have no hearing aid/s I use one hearing aid (leftear ) I use one hearing aid (rightear) I use two hearing aids (bothears) If you have been using hearing aid/s, for how long? ______ years ______ months or _____ weeks If you have two aids and have used them for different lengths of time, please write down both. SSQ 5.6 page 1

2. Speech Spatial Qualities (Part 1: Speech hearing) Not at all Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 2

3. Speech Spatial Qualities (Part 1: Speech hearing, continued) Not at all Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 3

4. Speech Spatial Qualities (Part 1: Speech hearing, continued) Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 4

5. Speech Spatial Qualities (Part 2: Spatial hearing) Not at all Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 5

6. Speech Spatial Qualities (Part 2: Spatial hearing, continued) Not at all Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 6

7. Speech Spatial Qualities (Part 2: Spatial hearing, continued) Not at all Not at all Not at all Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Inside my head Out there Not applicable Much closer Not closer Not applicable SSQ 5.6 page 7

8. Speech Spatial Qualities (Part 2: Spatial hearing, continued) Much further Not at all Not further Perfectly Not applicable Not applicable SSQ 5.6 page 8

9. Speech Spatial Qualities (Part 3: Qualities of hearing) Not at all Jumbled Not at all Not at all Not at all Not jumbled Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 9

10. Speech Spatial Qualities (Part 3: Qualities of hearing, continued) Not at all Not at all Not at all Not at all Not at all Perfectly Perfectly Perfectly Perfectly Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 10

11. Speech Spatial Qualities (Part 3: Qualities of hearing, continued) Concentrate hard Lots of effort Unnatural Not at all Not at all Not need to concentrate Natural Perfectly No effort Perfectly Not applicable Not applicable Not applicable Not applicable Not applicable SSQ 5.6 page 11

12. Speech Spatial Qualities (Part 3: Qualities of hearing, continued) Not at all Not at all Perfectly Perfectly Not easily ignore Easily ignore Not applicable Not applicable Not applicable SSQ 5.6 page 12