| 1. | When you listen to people speaking, how is the volume of speech sounds? |
| | Good | Too soft | Too loud | |
| 2. | Soft sounds, like people talking at a distance or whispers should sound soft through your hearing aids. How is the softness of the soft sounds? |
| | Good | Too soft | Too loud | |
| 3. | Loud sounds, like sirens or horns honking, should sound loud through your hearing aids, but not so loud that you need to turn them off. How is the loudness of loud sounds?
|
| | Good | Too soft | Too loud | |
| 4. | Noise is all around us. In fact, people without hearing loss are bothered by noise. So, some noise is normal. However, noise shouldn't be overwhelming when wearing your hearing instruments. How is the volume of noise or non-speech sounds?
|
| | Good | Too much | Too little | |
| 5. | Overall, how is the quality of the sounds you hear through your hearing instruments?
|
| | Good | Too sharp | Too muffled | Echoing |
| 6. | How is speech in quiet situations (such as two or three people talking in a living room or quiet restaurant)?
|
| | Good | Too soft | Too loud | Not clear |
| 7. | How is speech in noisy situations (such as a crowded restaurant or party)?
|
| | Good | Too soft | Too loud | Not clear |
| 8. | Frequently, when people wear hearing instruments, they comment that their voice sounds different. This is a normal occurence; however, it shouldn't be distracting when you're speaking. How does your own voice sound to you?
|
| | Good | Too sharp | Too hollow | Too muffled |
| | | Too booming | Too soft | Too loud |
| 9. | When you speak, where does your own voice sound like it is coming from?
|
| In front of my mouth | Right | Left | Nose |
| | | Throat | Inside my head | Far in front |
| 10. | Feedback is the high-pitched squealing/whistling sound some hearing aids make when one chews, smiles, or uses the phone. Are you experiencing feedback in these situations?
|
| | Yes | No | | |
| | If Yes, does it happen in your....?
|
| | Left ear | Right ear | Both ears | |
| | Does it happen when you chew or smile on your....?
|
| | Left ear | Right ear | Both ears | |
| | Does it happen when you use the phone on your....?
|
| | Left ear | Right ear | Both ears | |
| 11. | Are your hearing aids or earmolds comfortable in your ears?
|
| | Yes | No | | |
| 12. | Do you feel comfortable inserting your hearing aids or earmolds into your ears?
|
| | Yes | No | | |
| 13. | Do you feel comfortable using the controls on your hearing instruments (memory button, volume control, etc.)?
|
| | Yes | No | | |
| 14. | Do you feel comfortable changing the batteries in your hearing instruments?
|
| | Yes | No | | |
| 15. | How often do you use your hearing instruments?
|
| Every day | Once a week | 4-6 days a week | |
| | | 2-3 days a week | Not often | |
| 16. | About how long do you wear your hearing instruments each day?
|
| More than 15 hours | 11-15 hours | 6-10 hours | |
| | | 1-5 hours | Less than 1 hour | |
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