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?

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?

* 2. How often do others complain that you turn up the television/radio too loud?

* 3. How often would you have difficulties following conversations in a restaurant?

* 4. How often does your hearing limit or hamper your personal or social life?

* 5. How often would you have to ask others to repeat themselves?

* 6. How often is it difficult for you to hear in the presence of background noise?

* 7. How often do you find it difficult to hear the voices of women or children?

* 8. How often do you hear people speak, but fail to understand what they are saying?

* 9. How often do you feel as though others mumble?

* 10. How often do you feel stressed or tired when listening for long periods of time?

Office use: compare to companion questionnaire. Open ended questions for more information.

Hearing Pre-Assessment

Personal Information

Ready to Start Your Journey to Better Hearing?