Questionnaire

Thank you for the confidence you have demonstrated in our clinic by making an appointment to see us.

The aim of this intake form is to help us gain a clearer picture of your hearing and listening needs and to focus your thoughts on areas that cause you difficulty currently and the main improvements you wish to achieve.

Our treatment requires no written contracts to be signed, however it does rely upon honesty, cooperation and commitment. For this reason we ask you to take care in filling out the questionnaire. Your thoroughness guarantees a more accurate assessment and a more effective outcome for yourself..

In finishing, we look forward to your visit and hope that thinking about your current situation and areas you would like to improve prepares you for the experience.

Hearing inventory for adults

Step 1 of 4

25%

Name*
First Last
Email*
Does your hearing problem cause you to feel embarrassed when meeting new people?*
- Yes
- Sometimes
- No
Does a hearing problem cause you to feel frustrated when talking to members of your family?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty hearing/understanding co-workers, clients or customers?*
- Yes
- Sometimes
- No

Do you feel handicapped by a hearing problem?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when visiting friends, relatives or neighbours?
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty in the movies or theatre?*
- Yes
- Sometimes
- No
Does a hearing problem cause you to have arguments with family members?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when listening to TV or radio?*
- Yes
- Sometimes
- No

Do you feel that any difficulty with your hearing limits or hampers your personal or social life?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when at a café or restaurant with relatives or friends?*
- Yes
- Sometimes
- No
Please list the top three situations where you would most like to hear better. Be as specific as possible (eg. to hear colleague clear across the conference table)*