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Hearing Needs Assessment
To prepare for your first appointment at our office, please complete our new patient forms before arriving.
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1
Name
*
This field is required.
First Name
Last Name
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2
Name
First Name
Last Name
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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.
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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.
*
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5
What motivated you to make an appointment?
*
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6
On a scale from one to ten how much is your hearing loss impacting your daily routine?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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