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Hearing Needs Assesment

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HEARING NEEDS ASSESSMENT

1.What is your hearing aaid experience?

I have a hearing device and use it regularly on the right ear left ear.
I have a hearing device, but don't use it , or use it only occasionally.
I tried a hearing device , but returned it for credit.
I have inquried about hearing devices at another office(s),but did not purchase at that time.
I have never used a hearing device.

2.Using 1,2,3,AND 4,rank the following in order of importance to your regarding a hearing device:

Rank 1
Rank 2
Rank 3
Rank 4

3.What motivated you to come in today?

4.On a scale of 1-10, where do you feel that you are (Psychologically, emotionally, financially, etc.) regarding doing something about your hearing loss?(Please circle one)

1
2
3
4
5
6
7
8
9
10
not
Motivated		 very
Motivated

5.Please check the box which corresponds to your ability to hear in the situations listed and check how often you are in that situation.

Listening situation How well do you hear in this situation How often are you in this situation
 
Quite Room(1to2 people)
Restaurants
Car
Television
Church
Meetings/Lectures
Work Place
Telephone
Large Social Gatherings
poor fair good
rarelysometimesoften
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