Hearing Questionnaire

Hearing Questionnaire2017-11-21T12:29:00+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


    x

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