CIQOL 35 Form - Musemics

Skip to content

Home
Forms

Home
Forms

Please enable JavaScript in your browser to complete this form.

Cochlear Implant Quality of Life-35 Profile

ID: *

Date

INSTRUCTIONS: Think about your daily life with your cochlear implant (and/or hearing aid, if you also
use one). Answer how often each of the following statements applies to your feelings and
experiences. Answer how often each statement applies even if you don't use cochlear implants or
hearing aids.

1. I am able to have a conversation in a quiet place without asking the other person to repeat themselves

Never
Rarely
Sometimes
Often
Always

2. Other people’s voices sound clear and natural to me

Never
Rarely
Sometimes
Often
Always

3. I am able to have a conversation with a group of three or more people

Never
Rarely
Sometimes
Often
Always

4. I am able to have a conversation without asking the other person to repeat themselves

Never
Rarely
Sometimes
Often
Always

5. I can hear and understand without looking at the person speaking

Never
Rarely
Sometimes
Often
Always

6. I have to ask a lot of questions about what is being said in a conversation

Never
Rarely
Sometimes
Often
Always

7. I can understand a conversation in a crowded environment (restaurant, party, etc.)

Never
Rarely
Sometimes
Often
Always

8. I am able to have a conversation with someone in a noisy place without asking them to repeat themselves

Never
Rarely
Sometimes
Often
Always

9. I can understand strangers without lip-reading in a noisy place

Never
Rarely
Sometimes
Often
Always

10. I can follow the conversation in a group of five people in a crowded restaurant when I cannot see everyone

Never
Rarely
Sometimes
Often
Always

11. I feel comfortable being myself

Never
Rarely
Sometimes
Often
Always

12. My hearing loss makes me feel inadequate

Never
Rarely
Sometimes
Often
Always

13. My hearing loss makes me irritable

Never
Rarely
Sometimes
Often
Always

14. I keep quiet in a conversation to avoid saying the wrong thing

Never
Rarely
Sometimes
Often
Always

15. I become frustrated when I cannot follow a conversation

Never
Rarely
Sometimes
Often
Always

16. My hearing loss prevents me from listening to TV or radio

Never
Rarely
Sometimes
Often
Always

17. I am able to enjoy listening to the radio and TV

Never
Rarely
Sometimes
Often
Always

18. I am able to enjoy music

Never
Rarely
Sometimes
Often
Always

19. I can recognize certain melodies in music

Never
Rarely
Sometimes
Often
Always

20. Music sounds clear and natural to me

Never
Rarely
Sometimes
Often
Always

21. Everyday sounds (birds chirping, rain, car horns, etc.) are clear to me

Never
Rarely
Sometimes
Often
Always

22. Everyday sounds (microwave, birds chirping, rain, car horn) sound natural to me

Never
Rarely
Sometimes
Often
Always

23. I am able to distinguish sounds in nature

Never
Rarely
Sometimes
Often
Always

24. I am able to hear cars approaching in traffic

Never
Rarely
Sometimes
Often
Always

25. I can hear someone approaching from behind

Never
Rarely
Sometimes
Often
Always

26. I am able to follow a conversation with minimal effort

Never
Rarely
Sometimes
Often
Always

27. I am able to ignore competing sounds and focus on the person who is speaking

Never
Rarely
Sometimes
Often
Always

28. I can easily have a conversation in a noisy place (restaurant, party, store)

Never
Rarely
Sometimes
Often
Always

29. I have to concentrate when having a conversation

Never
Rarely
Sometimes
Often
Always

30. I have to concentrate when having a conversation with strangers when in a noisy place

Never
Rarely
Sometimes
Often
Always

31. If I am interested, I will join family or friends for a social event

Never
Rarely
Sometimes
Often
Always

32. I have the confidence to socialize

Never
Rarely
Sometimes
Often
Always

33. I avoid socializing with friends, relatives, or neighbors due to my hearing loss

Never
Rarely
Sometimes
Often
Always

34. I avoid social situations due to my hearing loss

Never
Rarely
Sometimes
Often
Always

35. I feel left out when I am with a group of people due to my hearing loss

Never
Rarely
Sometimes
Often
Always

error: Content is protected!!

Scroll to Top