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Audiology Consult Request & Questionnaire
1
Do you find it hard to follow conversations on the phone or in group settings?
YES
NO
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2
Do you have difficulty hearing the TV clearly?
YES
NO
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3
Do you ever experience ringing in the ears that doesn’t seem to go away?
YES
NO
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4
Are you a pensioner or have a DVA Gold Card or White Card?
YES
NO
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5
Do you have a hearing aid at the moment?
YES
NO
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6
Full Name
*
This field is required.
First Name
Last Name
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7
Phone Number
*
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8
Post Code
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