West Georgia Eye Care Hearing Evaluation

First Name *

Last Name *

Contact Number *

Email address

Please select today's date. * +

Do you ever experiece feelings of dizziness? *

Yes

No

Do you have ringing or other noises (tinnitus) in your ears? *

Yes

No

Do others complain that you watch televsision with the volume too high? *

Yes

No

Do you frequently have to ask others to repeat themselves? *

Yes

No

Do you have difficulty following conversations in groups or noisy situations? *

Yes

No

Do you have to sit up front in meetings or worship services in order to undersand the speaker? *

Yes

No

Do you have difficulty understanding women's or children's voices? *

Yes

No

Do you have trouble knowing where sounds are coming from? *

Yes

No

Do you have trouble understanding when someone talks to you from another room or is not looking directly at you? *

Yes

No

Do others tell you that you don't seem to hear them? *

Yes

No

Does it seem like others are mumbling when they talk to you? *

Yes

No

Do you avoid family meetings or social situations because you cannot understand what people are saying? *

Yes

No

Do you currently own hearing aids? *

Yes

No

If yes, are you satisfied with your current hearing aids? *

Yes

No

If yes, how old are your current hearing aids (in years)?