Ear Wax Removal
Help With Hearing
Hearing Assessment Questionnaire
Before we see you, we would be grateful if you can fill in the below questionnaire. Your answers will help us to provide audiology care to suit you.
Name
*
First
Last
Date Of Birth
*
Knowing more about your home life and occupation will help us to advise you appropriately. Do you live:
*
— Select —
Alone
With Someone
In A Care Home
Other
If Other Please Specify
What is your occupation (please include voluntary roles)?:
What is your expected outcome from your hearing test?
Your Ears & Hearing
How long have you had a problem with your hearing?
*
Which ear(s) does this problem effect?
Left
Right
Both
Have you had any sudden or rapid changes in your hearing (within 90 days)?
Yes
No
Does your hearing change on different days?
Yes
No
Do you get pain in your ears?
Yes
No
Do you get any infections or discharge from your ears (not including wax)?
Yes
No
Have you had any ear-related operations?
Yes
No
Have you ever had a perforated eardrum?
Yes
No
Do you hear any rushing, hissing, ringing, beating, pulsing or any other noises in your ears, often called tinnitus?
Yes
No
Do you have a strong sensitivity to everyday loud sounds that do not bother other people?
Yes
No
If you have answered 'Yes' to any of the above please give more details here
Have you ever seen an Ear, Nose and Throat specialist for ear, hearing or dizziness problems?
Yes
No
Have you ever seen an Ear, Nose and Throat specialist for ear, hearing or dizziness problems?
Do you wear hearing aids?
Yes
No
If yes, do you experience any problems with your hearing aids?
If no, would you want hearing aids if they may help you to hear better?
Hearing Difficulties
Please click the boxes to select any the situations in which you may find that your hearing affects you. If you feel no situations apply please leave this section blank.
1. One to one conversation in quiet.
2. One to one conversation in noise.
3. Conversations in a group with no background noise.
4. Conversation in a group with background noise.
5. Hearing the television or radio at normal volume.
6. Hearing a familiar speaker on the telephone.
7. Hearing an unfamiliar speaker on the telephone.
8. Hearing the phone ring from another room.
9. Hearing the doorbell or knocker.
10. Hearing in church or in a meeting
11. Hearing traffic.
12. Hearing the fire alarm.
13. Decreased social contact.
14. Feeling embarrassed or stupid.
15. Feeling left out.
16. Feeling upset or angry.
17. Other:
If other please explain:
Of the situations you ticked, which 3 are most affected by your hearing? Please enter the numbers that apply here.
Medical History
Do you experience any dizziness?
Yes
No
Have you ever been exposed to significant noise in your life?
Yes
No
Has anyone in your family had a hearing loss not associated with aging?
Yes
No
Do you have any skin allergies?
Yes
No
Do you have any altered sensation in your face, like numbness or tingling, or a droop?
Yes
No
Have you ever taken any medication that you were told may affect your hearing?
Yes
No
Have you had any head injuries or strokes?
Yes
No
Do you have problems with your eyesight (with or without glasses)?
Yes
No
Do you have problems with the feeling or movement in your fingers, for example do you have problems doing up buttons?
Yes
No
Do you have problems lifting your hands to your ears?
Yes
No
Do you have any difficulties with your memory?
Yes
No
Do you have a pacemaker, defibrillator or brain shunt fitted?
Yes
No
If you have answered 'Yes' to any of the above please give more details here
Do you have a device that you could use for a video consultation for future appointments via the internet (e.g. computer, tablet, smartphone)?
Yes
No
Current Locations
Coming Soon
Important Links
© 2024 · ILoveMyEars
© 2024 · ILoveMyEars
Current Locations
Coming Soon
Important Links
Menu
Ear Wax Removal
Help With Hearing
Ear Wax Removal Manchester
Ear Wax Removal Sale
Ear Wax Removal Bolton
Ear Wax Removal Bury
Ear Wax Removal Oldham
0161 513 9011
