Hearing Aid Evaluation Intake Form

Patient Name

1.Do you sometimes feel embarrassed when you meet new people because you struggle to hear? Yes/No

2. Do you feel frustrated when talking to members of your family because you have difficulty hearing them? Yes/No

3. Do you have difficulty hearing or understanding your coworkers, clients, or customers? Yes/No

4. Do you feel restricted or limited by a hearing problem? Yes/No

5. Do you have trouble hearing the TV or radio at levels that are loud enough for others? Yes/No

Telemedicine