Hearing Questionnaire

Hearing Questionnaire 2017-11-21T12:29:00+00:00

By filling out this form, we can help and advise you of the options available to you if we find that you could have some hearing loss.

Your Name (required)

Your Telephone Number (required)

Your Email (required)

Do you struggle to hear the TV?
yesno

Do you have problems hearing the doorbell or listening to people on the telephone?
yesno

Do you struggle in group conversation?
yesno

Do your family and friends comment or remark about your hearing?
yesno

Do you miss the beginnings or endings of words and sentences?
yesno

Do you struggle to hear female or children’s voices?
yesno

Do you find yourself feeling left out of conversations?
yesno

Do you ever find yourself trying to lip read?
yesno

Do you ever struggle to hear in a car?
yesno

Do you struggle to hear in background noise?
yesno