First Appointment Questionnaire

Title *

Name *

First

Last

Phone number *

Street number

Street name

Suburb

Postcode

Email *

How did you hear about us?

Comment or Message *

Are you an Australian government funded pensioner or veteran?

If yes, Pension or DVA Card Number

Tick the applicable box

Do you have private health insurance?

Have you had a hearing test before?

Have you had ear surgery?

Have you ever been exposed to loud noise?

Have you ever used hearing aids?

If yes, where did you obtain the hearing aids from?

Tick the boxes where you are experiencing problems with your current hearing aids

Other comments

Do you have trouble understanding in the presence of background noise?

Do you have trouble hearing family and friends at social gatherings?

Do you have trouble hearing in a one on one conversation

Do you have trouble understanding female or children’s voices?

Do others comment on the high volume of your TV or radio?

How important is hearing 1 on 1 Conversation?

Selected Value: 0

Please slide bar 0-not important, 10=very important)

How important is hearing the TV / Radio?

Selected Value: 0