How would you rate your hearing currently? *

POOR

FAIR

GOOD

EXCELLENT

How well do you hear when talking over the phone? *

POOR

FAIR

GOOD

EXCELLENT

Do you find yourself turning the TV volume up higher than what others set it to? *

ALWAYS

OFTEN

SOMETIMES

NEVER

Do people ever point out that you have misunderstood something that was said? *

ALWAYS

OFTEN

SOMETIMES

NEVER

How well do you follow conversations when multiple people are talking at the same time? *

POOR

FAIR

GOOD

EXCELLENT

Do you have trouble hearing in noisy environments, like restaurants or crowds? *

ALWAYS

OFTEN

SOMETIMES

NEVER

How well do you hear when someone talks to you in a soft voice or whisper? *

POOR

FAIR

GOOD

EXCELLENT

Have you been exposed to excessive noise at work, loud music, firearms or other noisy hobbies? *

ALWAYS

OFTEN

SOMETIMES

NEVER

Do you experience dizziness, pain or ringing in your ears? *

ALWAYS

OFTEN

SOMETIMES

NEVER

Full Name

Email *