This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submissions

*Required Field
Our goal is to maximize your ability to hear so that you can more easily communicate with others. In order to reach this goal, it is important that we understand your communication needs, your personal preferences, and your expectations. By having a better understanding of your needs, we can use our expertise to recommend the hearing aids that are most appropriate for you. By working together we will find the best solution for you.

Please complete the following questions. Be as honest as possible. Be as precise as possible. Thank you.
 

Please list the top three situations where you would most like to hear better. Be as specific as possible.  



How important is it for you to hear better?
(1 being not very important and 5 being very important)
How motivated are you to wear and use hearing aids?
(1 being not very motivated and 5 being very motivated)
How well do you think hearing aids will improve your hearing?
(1 being not very helpful and 5 being very helpful)
What is your most important consideration regarding hearing aids? Rank order the following factors with 1 as the most important and 4 as the least important.  Place an X on the line if the item has no importance to you at all.
 

Do you prefer hearing aids that: (select one)

Please check any the picture or pictures of the style oh hearing aid you would NOT be willing to use.
Your hearing healthcare professional will discuss with you if your choices are appropriate for you – given your hearing loss and physical shape of your ear.
 

Behind The Ear

Full Shell

Canal

Mini BTE

Behind The Ear

CIC
How confident do you feel that you will be successful in using hearing aids?
(1 being not very confident and 5 being very confident)
There is a wide range in hearing aid prices. The cost of hearing aids depends on a variety of factors including the sophistication of the circuitry (for example, higher level technology is more expensive than the more basic hearing aids) and size/style (for example, the CIC hearing aids are more expensive than the BTE instruments).

Thank you for answering the questions. Your responses will assist us in providing you with the best hearing healthcare.