Advamced Hearing Plus logo - hearing aids: testing, fittings, programming, servicing, repair

providing exceptional quality care for hearing impaired individuals all over Lane County, Oregon
shop for assisted listening devices with our associate Beyond Hearing Aids

Shopping

Assisted Listening
Devices Store


border graphic border graphic
 

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.

 
 
 
 
 
 
 
 

Questionnaire
1.   Do people seem to or speak in a softer voice than they used to?
Never
Occasionally
Frequently
All the time
2.   Do you feel 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 themselves?
Yes
No
4.   When you are in a group or in a 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 noise bother you?
Never
Occasionally
Frequently
All the time
6.   Do you often need to turn up the on your TV or radio?
Yes
No
7.   Do you find it difficult to hear the doorbell or the telephone ?
Never
Occasionally
Frequently
All the time
8.   Is carrying on a conversation difficult?
Never
Occasionally
Frequently
All the time
9.   Do you find it difficult to 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 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.		 
border graphic border graphic

   
[ 23 Nov 2007 ]privacy policy© 2003-2007 Advanced Hearing Plus
All rights reserved.
Valid XHTML 1.0 CSS2 Site redeveloped 2006 by 24 Carat Design.