Lifestyle Questionnaire

First Name *

Last Name *

Today's Date *

Email *

Phone *

Medical History

Reason for today's appointment: *

Allergies to medicines, plastics, etc...: *

Current Medications *

Have You Ever Had Ear Surgery? *

Yes

No

If Yes, Which Ear?

Left

Right

Both

Describe Surgery Type:

Please List All Major Surgeries In The Last 10 Years: *

Please List All Serious Illnesses In The Last 10 Years: *

Hearing History

When Was Your Last Hearing Exam? *

By Whom? *

What Were Their Recommendations? *

How Long Ago Did You Notice Difficulties In Your Hearing?

Have You Ever Used Assistive Listening Devices?

Yes

No

In Which Ear Do You Feel Your Hearing Is Poorer? *

Left

Right

Both Equally

Which Ear Do You Use On The Telephone? *

Left

Right

Both Equally

Have You Experienced Sudden Or Progressive Loss In The Last 90 Days? *

Yes

No

Have You Experienced Any Drainage From Your Ear(S) Within The Last 90 Days? *

Yes

No

Do You Suffer From Pain Or Discomfort In Your Ear(S)? *

Yes

No

Do You Suffer From Acute Or Chronic Dizziness? *

Yes

No

Hearing Assessment

1. Do You Feel Like People Are Mumbling Or Not Speaking Clearly? *

Yes

No

2. Do You Find Yourself Asking Others To Speak Up Or Repeat Themselves? *

Yes

No

3. Do You Find Men's Voices Easier To Understand Than Voices Of Women Or Children? *

Yes

No

4. Do You Experience Difficulty Understanding Soft Or Whispered Speech? *

Yes

No

5. Do You Have Difficulty Understanding Speech On The Telephone? *

Yes

No

6. Does Difficulty With Hearing Cause You To Visit Friends, Relatives Or Neighbors Less Often Than You Would Like? *

Yes

No

7. Do You Experience Ringing Or Noises In Your Ears? *

Yes

No

8. Do You Find It Difficult To Understand A Speaker At A Public Meeting Or Religious Service? *

Yes

No

9. Do You Find It Difficult To Follow A Conversation In A Noisy Or Crowded Room? *

Yes

No

10. Do You Spend Time In Loud Environments (Concerts, Sporting Events Etc.) Where You Need To Hear In The Presence Of Background Noise? *

Yes

No

11. Do You Attend Work Or Social Meetings Where You Need To Be Able To Communicate Amidst Group Conversation? *

Yes

No

12. Are You Actively Working Or Need To Communicate With People Throughout The Day? *

Yes

No

Listening Environment Rating

Please provide the top three listening situations where you would like to hear better.

Listening Environment 1 *

Listening Environment 2 *

Listening Environment 3

Lifestyle Considerations

What Factors are important to you? (select all that apply) *

Cosmetics

Price

Handling/ dexterity

Ease of use/ automatic

What type of phone(s) do you usually use? *

Desk or wall

Speaker or handset

Mobile

I agree to the privacy policy provided by the company. By providing my contact information, I agree to be contacted via the provided channels. I understand I can opt out of communication at any time.

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