Gruppo Hearing Survey
Good day! Gruppo Hearing is committed in providing a total solution for people with hearing difficulties. To accomplish this goal, we would appreciate your help by filling out the following survey. Thank you!
1.Demographic Data
Name of Recipient
First name *
Your answer
Last name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Age *
Your answer
Hearing Age
Time since the child received hearing aids and/or cochlear implants.
Your answer
Gender *
City *
Your answer
2.Hearing Device
Type of Hearing Device
Your answer
Date of Implant Switch-On/ Amplification
Date on which hearing aids and/or cochlear implants switch-on
MM
/
DD
/
YYYY
Which ear is the Hearing Device placed
3.Services Availed
Therapy Services
If undergoing therapy
Name of center
Your answer
Educational Placement
If enrolled
Name of School
Your answer
Grade level/Level in School
Your answer
4.Are you interested in attending a parent education seminar?
5.If yes, please choose 5 topics you are most interested in
Date taken
*
MM
/
DD
/
YYYY
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