Online Hearing Screening Name *Phone *Email Address *Have you worn hearing aids in the past? *YesNoWhat style of hearing aids did you wear previously?In The Canal (ITC)In The Ear (ITE)Behind the Ear (BTE)Receiver in the Canal (RIC)Completely in the Canal (CIC)Does a hearing problem cause you to feel embarrassed when meeting new people? *YesSometimesNoDoes a hearing problem cause you to feel frustrated when talking to members of your family? *YesSometimesNoDo you have difficulty hearing when someone speaks in a whisper? *YesSometimesNoDo you feel handicapped by a hearing problem? *YesSometimesNoDoes a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? *YesSometimesNoDoes a hearing problem cause you to attend group gatherings, such as religious services or volunteer activities, less often than you would like? *YesSometimesNoDoes a hearing problem cause you to have arguments with family members? *YesSometimesNoDoes a hearing problem cause you difficulty when listening to TV or radio? *YesSometimesNoDo you feel that any difficulty with your hearing limits or hampers your personal or social life? *YesSometimesNoDoes a hearing problem cause you difficulty when in a restaurant with relatives or friends? *YesSometimesNoSubmit Screening
