Hearing Aid Self-Exam

Do you think you have hearing loss?

Would you like to know how to take the first step towards correction? Answer the following questions below to request the results of your self-exam. We will contact you with recommendations based on your responses.

1. I have difficulty hearing in a group of people. Please select an option... Always Almost always Sometimes Almost never Never 2. I hear people speak, but have difficulty understanding the words. Please select an option... Always Almost always Sometimes Almost never Never 3. I have difficulty hearing on the telephone. Please select an option... Always Almost always Sometimes Almost never Never 4. I set the volume on the television louder than others would like. Please select an option... Always Almost always Sometimes Almost never Never 5. I have trouble hearing in church, at the movies and in other public places. Please select an option... Always Almost always Sometimes Almost never Never 6. I have difficulty hearing children speak. Please select an option... Always Almost always Sometimes Almost never Never 7. I cannot hear a digital watch or alarm clock beep. Please select an option... Always Almost always Sometimes Almost never Never 8. I have to ask friends and family to repeat what they say. Please select an option... Always Almost always Sometimes Almost never Never 9. I have trouble following a conversation with 2 or more people involved. Please select an option... Always Almost always Sometimes Almost never Never 10. I find it hard to determine the direction from where the sound is coming from. Please select an option... Always Almost always Sometimes Almost never Never 11. I find myself avoiding social events because of difficulty hearing others. Please select an option... Always Almost always Sometimes Almost never Never 12. I get complaints that I misunderstand what people say to me. Please select an option... Always Almost always Sometimes Almost never Never 13. I find myself asking people to speak more clearly. Please select an option... Always Almost always Sometimes Almost never Never 14. I have worked in places where there were loud noises airports, heavy equipment. Please select an option... Always Almost always Sometimes Almost never Never 15. I reply to people inappropriately because I misunderstand what they say. Please select an option... Always Almost always Sometimes Almost never Never 16. I have a hearing aid. Please select an option... Yes No 17. I have had this hearing aid for: Please select an option... Not applicable Less than a year 1 to 5 years More than 5 years

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Phone: Email: How would you like to receive your results? Email Phone call Postal Service How did you hear about us? Please select an option... Searching the Web Link from another Website Friend Television Radio Questions or comments:

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