Name
_______________________________________________________________________________________________________________________ |
Birth date: _____/_____/_____ |
Date: _____/_____/_____ |
Instructions |
Please find below questions on your hearing aids.
Please circle the letter that best characterizes your answer to
each question. The list of words to the right describes the
meaning of each letter. |
A - Not at all |
B - A little |
C - Somewhat |
D - Medium |
E - Considerably |
F - Greatly |
G - Tremendously |
Remember that your answers need to reflect your
general opinion on the hearing aids you are wearing now or the
device you have used more recently. |
1 - Do your hearing aids help you understand what
the people who talk to you more frequently say when compared to
when you do not have your aids on? |
[A] [B] [C] [D] [E] [F] [G] |
2 - Are you frustrated when your device captures
sounds that do not allow you to hear the sounds you would like
to have heard? |
[A] [B] [C] [D] [E] [F] [G] |
3 - Are you convinced that buying your hearing aids
was your best option? |
[A] [B] [C] [D] [E] [F] [G] |
4 - Do you think that people realize more now that
you have hearing loss when you are wearing your hearing
aids? |
[A] [B] [C] [D] [E] [F] [G] |
5 - Have your hearing aids reduced the number of
times you have to ask people to repeat what they had said? |
[A] [B] [C] [D] [E] [F] [G] |
6 - Do you think your hearing aids compensate your
handicap? |
[A] [B] [C] [D] [E] [F] [G] |
7 - Are you upset for not being able to have the
volume you wished without your device beeping? |
[A] [B] [C] [D] [E] [F] [G] |
8 - How satisfied are you with the appearance of
your hearing aids? |
[A] [B] [C] [D] [E] [F] [G] |
9 - Has your self-confidence improved now that you
are wearing hearing aids? |
[A] [B] [C] [D] [E] [F] [G] |
A - Not at all |
B - A little |
C - Somewhat |
D - Medium |
E - Considerably |
F - Greatly |
G - Tremendously |
10 - How natural is the sound you receive from your
hearing aids? |
[A] [B] [C] [D] [E] [F] [G] |
11 - How much have your hearing aids helped you talk
on telephones without amplifiers? (If you can hear well on the
phone without your hearing aids, check here.) |
[A] [B] [C] [D] [E] [F] [G] |
12 - How competent was the person who provided you
with your hearing aids? |
[A] [B] [C] [D] [E] [F] [G] |
13 - Do you think wearing hearing aids makes you
feel less capable? |
[A] [B] [C] [D] [E] [F] [G] |
14 - Does the cost of the hearing aids seem
reasonable to you? |
[A] [B] [C] [D] [E] [F] [G] |
15 - Are you satisfied with the quality of your
hearing aids (in regards to how often it had to be
repaired)? |
[A] [B] [C] [D] [E] [F] [G] |
Please answer the following additional items: |
Experience with current hearing aids: |
[ ] Less than six weeks |
[ ] Six weeks to 11 months |
[ ] One to 10 years |
[ ] More than 10 years |
Overall experience with hearing aids (past and
current). |
[ ] Less than six weeks |
[ ] Six weeks to 11 months |
[ ] One to 10 years |
[ ] More than 10 years |
Daily use of hearing aids: |
[ ] None |
[ ] Less than one hour per day |
[ ] One to four hours per day |
[ ] Four to eight hours per day |
[ ] Eight to 16 hours per day |
Degree of hearing difficulty (without hearing
aids) |
[ ] None |
[ ] Medium |
[ ] Moderate |
[ ] Moderate to severe |
[ ] Severe |
Other
comments:___________________________________________________________________________________________________________________ |
Hearing aid characteristics: (check all
applicable) |
[ ] Directional microphone |
[ ] Multiple microphones |
[ ] Multichannel |
[ ] Remote control |
[ ] Multi-memory |
[ ] High cut |
[ ] Compression |
[ ] TILL |
[ ] WDRC |
[ ] BILL |
[ ] Telephone coil |
[ ] Other
___________________________________________________________________________________________________________________ |
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