207-1160 Burrard Street, Vancouver, B.C. V6Z 2E8
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(604) 687-1488
Request an Appointment
About Us
About Us
Our Guarantee
Vision Mission Goals
Our Team
Your Privacy
Services
Services
Treatment Plan
Hearing Pre-Assessment
Aural Rehabilitaion
Products
Products
Hearing Instruments
Hearing Aid Re-Training Instructions
Accessories
Hearing Aid Accessory Instructions
Troubleshooting a Hearing Aid
Musicians
Your Hearing
Your Hearing
How we hear
Communicating better
Tinnitus
Interesting Links
Interesting Links
Foods for Better Hearing
Events
Blog
Contact Us
Frequently Asked Questions
Contact Us
Testimonials
Hearing Pre-Assessment
Do you wonder whether or not you have hearing loss?
This is a quick questionnaire that can be completed prior to a full hearing evaluation by an Audiologist. It is designed to give us more information about your current hearing experiences. It does not in any way replace the need for a full and complete audiology evaluation by an Audiologist.
Please complete and submit your responses to the clinic prior to your appointment. Thank you.
Personal Information
*
Your Name:
*
Email:
Your Telephone Number:
*
Would you like the clinic to contact you?
- Select one -
Yes
No
Please mark the columns which best describes the frequency with which you experience each situation or feeling listed below:
*
1. How often do you find it difficult to converse on the phone?
- Select one -
Always
Frequently
Sometimes
Never
*
2. How often do others complain that you turn up the television/radio too loud?
- Select one -
Always
Frequently
Sometimes
Never
*
3. How often would you have difficulties following conversations in a restaurant?
- Select one -
Always
Frequently
Sometimes
Never
*
4. How often does your hearing limit or hamper your personal or social life?
- Select one -
Always
Frequently
Sometimes
Never
*
5. How often would you have to ask others to repeat themselves?
- Select one -
Always
Frequently
Sometimes
Never
*
6. How often is it difficult for you to hear in the presence of background noise?
- Select one -
Always
Frequently
Sometimes
Never
*
7. How often do you find it difficult to hear the voices of women or children?
- Select one -
Always
Frequently
Sometimes
Never
*
8. How often do you hear people speak, but fail to understand what they are saying?
- Select one -
Always
Frequently
Sometimes
Never
*
9. How often do you feel as though others mumble?
- Select one -
Always
Frequently
Sometimes
Never
*
10. How often do you feel stressed or tired when listening for long periods of time?
- Select one -
Always
Frequently
Sometimes
Never
Office use: compare to companion questionnaire. Open ended questions for more information.
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