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Hearing Survey 2
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Choose
Mr
Mrs
Ms
Miss
Frst Name
Your answer
Last Name
Your answer
Do you experience any of the following in regards to your ears?
Yes
No
Left
Right
Discharge / Infection
Perforated Ear Drum
Pain / Pressure / Discomfort
Ringing / Buzzing (Tinnitus)
Fluctuating Hearing Loss
Sudden or Recent Hearing Loss
Numbness in Face
Dizziness / Vertigo
Yes
No
Left
Right
Discharge / Infection
Perforated Ear Drum
Pain / Pressure / Discomfort
Ringing / Buzzing (Tinnitus)
Fluctuating Hearing Loss
Sudden or Recent Hearing Loss
Numbness in Face
Dizziness / Vertigo
Clear selection
Have you ever had ear surgery?
Yes
No
Clear selection
If you have had surgery what have you had done?
Your answer
Do you have any family history of hearing loss:
Yes
No
Clear selection
Have you ever worked in noise?
Yes
No
Clear selection
How long have you had difficulty hearing?
Your answer
Have you ever been fitted with a hearing aid before:
Yes
No
Clear selection
If yes, who fitted your hearing aid?
Your answer
Do you currently wear hearing aids?
Yes In-the-Ear
Yes Behind-the-Ear
No
Clear selection
Are you in a medical Benefits Fund?
Yes
No
Clear selection
Does your medical Benefits Fund cover you for hearing aids?
Yes
No
Clear selection
What is your Doctor’s Name
Your answer
Where is your doctor located (address)
Your answer
Have you seen an ENT specialist
Yes
No
Clear selection
What is your ENT specialists name
Your answer
Please select if you have difficulty hearing in the following situations:
Hearing the Television at normal volume
Hearing the telephone ring & hearing people on the phone
Hearing husband, Wife, Children in the same room
Hearing One to One conversations
Hearing small group conversation in quiet
Hearing conversation at the dining room table
Hearing at family gatherings
Hearing in social groups
Hearing at Bowling / Golf Club
Hearing at Meetings / Lectures
Hearing at Church
Hearing at the theatre / movies
Hearing when shopping
Hearing in the bus / car
Clear selection
How often are you with a group of people at a social gathering?
Most days of the week
A couple of days per week
A couple of days per month
A few days per year
Rarely
Clear selection
If you were to need a hearing aid, please rank the following from mostimportant (1) to least important (5).
1
2
3
4
5
Size of the aid
Easy controls
Clarity in sound
Cost of the aid
1
2
3
4
5
Size of the aid
Easy controls
Clarity in sound
Cost of the aid
Clear selection
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