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Name

Patient Name

Relationship

Date

In our professional experience, we have found that many of our patients describe hearing loss as the perception of Sound Voids® that affect not only their normal daily routines but the lives of those around them. We would like to ask you a few situational questions to better understand your companion's listening lifestyle and how we might improve their quality of life.

How often does your companion's hearing...

Make it difficult for your companion to converse on the telephone? Frequently Sometimes Rarely

Cause you to complain that your companion turns up the television or radio too loud? Frequently Sometimes Rarely

Cause your companion to have difficulty following conversations in a restaurant? Frequently Sometimes Rarely

Limit or hamper your companions personal or social life? Frequently Sometimes Rarely

Cause your companion to have to ask people to repeat themselves? Frequently Sometimes Rarely

Cause your companion to have difficulty hearing when in the presence of background noise? Frequently Sometimes Rarely

Cause your companion to have difficulty hearing women's or children's voices? Frequently Sometimes Rarely

Cause your companion to hear people speak but fail to understand what they are saying? Frequently Sometimes Rarely

Cause your companion to feel as though others mumble? Frequently Sometimes Rarely

Cause your companion to feel stressed or tired when listening for long periods of time? Frequently Sometimes Rarely

Please provide the top three listening situations where you would like your companion to hear better.

Situation 1 Situation 2 Situation 3