Listening & Lifestyle Needs

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Please select the response that best describes your listening & lifestyle needs.

Your Name *

Today's Date *

YYYY

I am actively working & need to communicate with many people throughout the day. *

Never

Seldom

Occasionally

Often

Please select one:

I spend time at sporting events or other loud activities where I need to hear in the presence of much background noise. *

Never

Seldom

Occasionally

Often

Please select one:

I attend large parties or go to busy restaurants where I need to communicate. *

Never

Seldom

Occasionally

Often

Please select one:

I go shopping or spend time in public places where being able to communicate is important. *

Never

Seldom

Occasionally

Often

Please select one:

I need to be able to hear at a distance in a large room such as: Live Theater, Church/Synagogue/Mosque, Lecture Hall/Auditorium. *

Never

Seldom

Occasionally

Often

Please select one:

I attend work or social meetings where I need to be able to communicate. *

Never

Seldom

Occasionally

Often

Please select one:

I need to be able to communicate in small group settings. *

Never

Seldom

Occasionally

Often

Please select one:

I have difficulty hearing in quiet situations. *

Never

Seldom

Occasionally

Often

Please select one:

I have difficulty hearing & understanding on the telephone. *

Never

Seldom

Occasionally

Often

Please select one:

I have difficulty hearing & understanding voices on the television. *

Never

Seldom

Occasionally

Often

Please select one:

Please list the top 3 situations where you would like most to hear better. Be as specific as possible: *

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