Check yourself or someone you know with these questions.   * Name: * Address: * City, State, Zip:   Day/Evening Phone:   Fax: * E-mail:   Do people seem to mumble more frequently?   Yes No Do you hear but have trouble understanding?   Yes No Do you often ask people to repeat what they have said?   Yes No Do you find telephone conversations increasingly difficult?   Yes No Does your family complain that you play the TV or radio to loudly?   Yes No Do you no longer hear normal household sounds such as the dripping of a faucet or ringing of a doorbell?   Yes No Do you have trouble hearing when your back is turned to the speaker?   Yes No Have you been told that you speak too loudly?   Yes No If you have experienced two or more of these symptoms, you qualify for a thorough hearing test. * Indicates a required field