Customer Feedback
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Name
Address
Phone Number
Date
MM
/
DD
/
YYYY
1. Do you usually wear?
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2. On average, how often do you wear your hearing aid?
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If you never wear your hearing aid, please tell us why
3. How much has your hearing aid helped you with any of the following?
A lot
A little
Not at all
Help not needed
Family
Small group conversation
Meetings (committees, Church)
Social Activities (shopping, bowls)
Television / Radio
Telephone
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4. Current difficulties with the hearing aid
Yes
No
Do you have difficulty positioning the hearing aid or removing it?
Do you have difficulty adjusting the controls of the hearing aid?
Does the aid whistle when it is in your ear and set at a comfortable level?
Does the fit of the hearing aid or earmould cause you any discomfort?
Does the hearing aid make any sudden, unbearably loud noises?
Does the sound of your own voice sound hollow or like it is echoing?
Do other people help you adjust your hearing aid?
If you have a remote control, do you have difficulty using it?
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5. How would you describe your satisfaction with your hearing aid?
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6. How would you describe your satisfaction with your hearing aid repair service atAbout Bass Coast Hearing?
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7. How would you describe your satisfaction with the way you have been treated atAbout Bass Coast Hearing?
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8. The thing I liked best about the hearing aid or service was
9. The thing I liked least about the hearing aid or service was
10. If I were to make a change to the hearing aid or service, it would be
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