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 ask others to repeat themselves in a quiet situation?

* 2. How often do you ask others to repeat themselves in a noisy situation?

* 3. Do others complain that you turn the television/radio up too loudly?

* 4. How often do you have difficulty following conversations in background noise? (eg. restaurants, group meetings)

* 5. How often do you find it difficult to hear women or children's voices, or other high pitched sounds (eg. birdsong)?

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

* 7. Do you feel as though others mumble?

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

* 9. Does your hearing limit your personal or social life?

* 10. Are there any other listening situations you struggle in?

Hearing Pre-Assessment

Personal Information

Ready to Start Your Journey to Better Hearing?