providing exceptional quality care for hearing impaired individuals all over Lane County, Oregon

Hearing Loss Questionnaire

Your answers to these questions only provide an early indication of whether or not you may have impaired hearing. What your score means:

If you answer "Yes", "Frequently", or "All the time" to just 1 or 2 of these questions, you may not need hearing help just yet.
If you answer "Yes", "Frequently", or "All the time" to 3 of these questions, you may be experiencing some hearing loss.
If you answer "Yes", "Frequently", or "All the time" to 4 or more of these questions, we urge you to seek out a qualified hearing care professional for a hearing test that will determine your hearing loss.

We will respond only if you enquire about receiving further help.

Your personal information gathered from this form will not be collected or used by third parties since we value our visitors' and customers' privacy.

The fields indicated with an asterisk (*) are required to be completed.

*First Name
*Last Name
*Age
*City
*State/Province
*Zip/Postal Code
*Country
*E-mail
Questionnaire
1. Do people seem to mumble or speak in a softer voice than they used to?
Never Occasionally Frequently All the time
2. Do you feel tired or irritable after a long conversation?
Never Occasionally Frequently All the time
3. Do you sometimes miss key words in a sentence or frequently need to ask people to repeat themselves?
Yes No
4. When you are in a group or in a crowded restaurant, is it difficult for you to follow the conversation?
Never Occasionally Frequently All the time
5. When you are together with other people, does background noise bother you?
Never Occasionally Frequently All the time
6. Do you often need to turn up the volume on your TV or radio?
Yes No
7. Do you find it difficult to hear the doorbell or the telephone ring?
Never Occasionally Frequently All the time
8. Is carrying on a telephone conversation difficult?
Never Occasionally Frequently All the time
9. Do you find it difficult to pinpoint where an object is (e.g. an alarm clock or a telephone) from the noise it makes?
Never Occasionally Frequently All the time
10. Has someone close to you mentioned that you might have a problem with your hearing?
Never Occasionally Frequently All the time
Comments:

Thanks for taking our questionnaire. We will be in contact with you if you would like to receive further help.

Advanced Hearing Plus, Inc. Team

Office Hours
Monday thru Friday 9-5
Saturday by appointment only

Address and Phone
816 Beltline Rd
Springfield, OR 97477
Telephone: 541-746-7671
Toll Free: 800-230-1953

Before or after hours, you are welcome to
call and leave a message on our machine.


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