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Your responses to the following statements will assist me in determining your specific hearing concerns and needs. Please assign a numerical value from "1-5" to each of the ten statements below. An explanation of each value is noted below for your reference.

1 = increasingly apparent
2 = mild problem
3 = moderate problem
4 = very difficult
5 = cannot function in this situation

The same number can be assigned to more than one statement.
Listening to my spouse/relative in quiet one-to-one conversations.
Listening to my spouse/relative in the presence of background noise.
I depend on my spouse/relative to let me know what is going on during a television show/movie because I miss the plot
I choose to stay away from difficult hearing situations, especially during group gatherings
My spouse/relative complains that the television is too loud.
Listening to multiple persons in a group gathering.
My spouse/relative complains that I often ignore them especially when they are facing the opposite direction from me.
I often have problems hearing people when they are speaking to me from another room
My spouse/relative complains that I have "selective hearing".
My spouse/relative "mumbles".
  Have you had a consult for a hearing aid in the past?

If so, When?

  Have you purchased a hearing aid in the past?

If so, When?

  Which Ear or both?

What was the cost?


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