Your Hearing Questionnaire - BELTONE™ Hearing Innovations (Pty) Ltd

1. Do People around you seem to mumble *

2. Have you ever been embarrassed because you couldn't hear or misunderstood something being said to you?* *

3. Do you often ask people to repeat themselves?* *

4. Do you have trouble hearing on the telephone?* *

5. Does your family complain that you play the TV or radio too loudly?* *

6. Do you sometimes have trouble hearing household sounds like a faucet dripping, a clock ticking or a doorbell ringing?* *

7. Is it hard to hear when you can't see the speaker's face?* *

8. Do some people say that you speak too loudly?* *

9. Have you ever experienced ringing in your ears?* *

10. Are conversations in restaurants or crowded places difficult?* *

11. Are you currently making use of a hearing aid?* *

What is your age? *

Which area do you reside in? *

Name *

First

Last

Contact/Cellphone Number? *

E-mail address *