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Hearing Needs Assessment
To prepare for your first appointment at our office, please complete our new patient forms before arriving.
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HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Name
First Name
Last Name
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3
What is your hearing aid experience?
*
This field is required.
I have a hearing device and use it regularly on the left ear.
I have a hearing device and use it regularly on both ears.
I have a hearing device, but don't use it, or use it only occasionally.
I tried a hearing device but returned it for credit.
I have inquired about hearing devices at another office(s), but did not purchase at that time.
I have never used a hearing device.
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4
Rank the following in order of importance to you regarding a hearing device, with 1 being the most important and 5 the least important.
*
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5
What motivated you to make an appointment?
*
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6
On a scale from one to ten how much is your hearing loss impacting your daily routine?
*
This field is required.
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7
Quiet Room (1 to 2 people)
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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8
Restaurants
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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9
Car
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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10
Watching Television
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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11
Church
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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12
Meetings/ Lectures
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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13
Work Place
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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14
Telephone Calls
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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15
Large Social Gatherings
Please Select
Poor
Fair
Good
Please Select
Please Select
Poor
Fair
Good
How well do you hear in this situation?
Please Select
Rarely
Sometimes
Often
Please Select
Please Select
Rarely
Sometimes
Often
How often are you in this situation?
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