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Hearing Evaluation and Auditory Rehabilitation

How to complete this Questionnaire:

  • To let us know more about your hearing loss, please answer the following questions
  • There are no "right" or "wrong" answers, and only you can provide this information.
  • Because we want to know how you feel about your problems, whenever a statement represents an area or activity of your life where you have a problem, please indicate HOW MUCH OF A PROBLEM it is to you.
  • If a statement is not appropriate to your situation or if you are not having a problem in this area, circle the "0" and go on to the next statement.
  • If you are now wearing a hearing aid, please answer these questions thinking about your hearing loss and hearing aid.
  1. Considering how severe the problem is and how frequently it happens, please rate each item below on how “bad” it is by circling the number that corresponds with how you feel
  2. Please rank the 5 most important items affecting your health in the column to the right with a number 1 to 5 (maximum of 5 items)
0 = No problem
1 = Mild problem
2 = Moderate problem
3 = Severe problem
Speech muffled
Difficulty distinguishing direction of sounds
My intelligence or competency questioned due to my inability to completely hear others speak
Difficulty hearing speaker who is further away from me
Difficulty hearing telephone ring/alarm clock/door bel
Difficulty hearing when in a group or noisy situation
Difficulty communicating to family, friends, or others not familiar with my hearing problem
Difficulty communicating in car
Difficulty hearing on telephone
Difficultyhearing television or radio
Decreased enjoyment of music/movies/plays/outdoor performances / house of worship
Hearing loss causes frustration
Hearing loss causes embarrassment
Hearing loss causes increased anxiety or nervousness
First Name
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DOB
Email
Phone number
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  • Phone 1300 952 808
  • Email info@melbentgroup.com.au
  • Address G2/173 Lennox Street Richmond VIC 3121
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