Linda Kiser, AuD Hearing Survey

1
Are there situations in which you find it difficult to hear clearly?
Almost Always
Half the Time
Occasionally
Never
2
Do you have to strain to understand conversations?
Almost Always
Half the Time
Occasionally
Never
3
Do you have a problem hearing over the telephone?
Almost Always
Half the Time
Occasionally
Never
4
Do you have trouble following a conversation when two or more people are talking at the same time?
Almost Always
Half the Time
Occasionally
Never
5
Do you have trouble hearing conversations in a noisy background such as a restaurant or a group gathering?
Almost Always
Half the Time
Occasionally
Never
6
Do you have dizziness, pain, or ringing in your ears?
Almost Always
Half the Time
Occasionally
Never
7
Do family members or coworkers remark about you missing what has been said?
Almost Always
Half the Time
Occasionally
Never
8
Do people complain that you turn the TV volume up too high?
Almost Always
Half the Time
Occasionally
Never
9
Do you find it hard to hear someone when they talk in a soft voice or whisper?
Almost Always
Half the Time
Occasionally
Never
10
Do you find understanding women and children particularly challenging?
Almost Always
Half the Time
Occasionally
Never
11
Calculation
12
Name
First Name
Last Name
13
Email
example@example.com
14
What can we help you with?
New hearing aids / technology / evaluation
New hearing aids / technology / evaluation
Hearing aid less than three years old - adjust / clean / repair
Hearing aid more than three years old - adjust / clean / repair
Hearing protection - musician / hunting / industrial
Hearing test / evaluation
Ringing in my ear / tinnitus or dizziness
General information about hearing loss / hearing aids
Other
15
You are experiencing many signs of a hearing loss. It is highly recommended that you contact our office today for an appointment to meet with a hearing professional.
16
It appears you may be experiencing signs of a hearing loss. A hearing test can help detect early signs. We recommend contacting our office to schedule a hearing test.
17
You are not experiencing common signs of hearing loss. However, if you suspect you may have hearing loss or are experiencing other symptoms not listed here, please contact our office for a consultation.
Should be Empty: