You can always press Enter⏎ to continue
Hearing Needs Assessment
To prepare for your first appointment at our office, please complete our new patient forms before arriving.
START
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Name
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
What is your hearing aid experience?
*
This field is required.
I have a hearing device and use it regularly on the left ear.
I have a hearing device and use it regularly on both ears.
I have a hearing device, but don't use it, or use it only occasionally.
I tried a hearing device but returned it for credit.
I have inquired about hearing devices at another office(s), but did not purchase at that time.
I have never used a hearing device.
Previous
Next
Submit
Press
Enter
4
Rank the following in order of importance to you regarding a hearing device, with 1 being the most important and 5 the least important.
*
This field is required.
Previous
Next
Submit
Press
Enter
5
What motivated you to make an appointment?
*
This field is required.
TextSize
Created with Sketch.
Huge
Large
Normal
Small
Bold
Created with Sketch.
Italic
Created with Sketch.
Underline
Created with Sketch.
Underline Copy
Created with Sketch.
Ok
NumberList Copy 2
Created with Sketch.
quote
Created with Sketch.
Break
Created with Sketch.
Image
Created with Sketch.
Ok
Smiley
Created with Sketch.
Previous
Next
Submit
Press
Enter
6
On a scale from one to ten how much is your hearing loss impacting your daily routine?
*
This field is required.
Previous
Next
Submit
Press
Enter
7
Quiet Room (1 to 2 people)
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
8
Restaurants
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
9
Car
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
10
Watching Television
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
11
Church
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
12
Meetings/ Lectures
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
13
Work Place
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
14
Telephone Calls
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
15
Large Social Gatherings
Poor
Fair
Good
Poor
Fair
Good
How well do you hear in this situation?
Rarely
Sometimes
Often
Rarely
Sometimes
Often
How often are you in this situation?
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
15
See All
Go Back
Submit
