Hearing screening questionnaire

2. Do you have any problems understanding when many people speak together?*
Yes Sometimes No

3. Do you have any problems understanding when you don't see the face of the person who is speaking?*
Yes Sometimes No

4. Do you have any problems understanding when there is noise around you?*
Yes Sometimes No

5. Do you find that people mumble or do not speak loud enough (on T.V., friends, doctors)?*
Yes Sometimes No

6. Do you find that people speak too fast (on T.V., friends, doctors)?*
Yes Sometimes No

8. Do you have any problems hearing the water running in the sink or bathtub when you are in another room?*
Yes Sometimes No

9. Do you have any problems hearing the phone ringing when you are in another room or in the bathroom (at home or at other people's houses)?*
Yes Sometimes No

10. Do you have any problems hearing the doorbell at home or at other people's houses?*
Yes Sometimes No

11. Do you have difficulty hearing when someone knocks on the door?*
Yes Sometimes No

12. Have your family, friends, or neighbours made any comments about the volume of your radio or television being too loud?*
Yes Sometimes No

13. Do you have a tendency to avoid other people because you are afraid of not understanding them?*
Yes Sometimes No

14. Do you prefer to avoid activities because of the noise around you (i.e., dining room, restaurant, family gathering, bingo)?*
Yes Sometimes No

15. How do you consider your hearing?*
Good Slight hearing problem (occasional hearing problem) Moderate hearing problem (frequent hearing problem) Serious hearing problem (important hearing problems, nearly always)

Please fill out the following fields to obtain your results by email :
First name:*
Last name :*
Email :*
Postal code :*
City :
Phone number
- I agree to receive hearing health news 2 to 3 times a year.
To make sure you receive your results by email, you may add the email address services@polycliniquedeloreille.com to your contact list.
By clicking “Send,” you consent to sharing your personal information with Polyclinique de l’Oreille and to being contacted by Polyclinique de l’Oreille to answer your questions, all in accordance with the Security and Privacy Policy.
Email
This field is for validation purposes and should be left unchanged.

Obtain your results by answering the questionnaire