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Name
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First
Last
Phone
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Email
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Which clinic location is most convenient for you?
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Lawrence
Bonner Springs
Do you find yourself having difficulty hearing in the presence of background noise?
*
Yes
No
Maybe
Do you find yourself watching a persons lips closely to follow the conversation?
*
Yes
No
Maybe
Do you feel that you have to strain to hear when someone talks or whispers?
*
Yes
No
Maybe
Do you feel people mumble when they talk to you?
*
Yes
No
Maybe
Do you ask people to repeat what was said?
*
Yes
No
Maybe
Do you find yourself turning up the television?
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Yes
No
Are loud sounds overly bothersome?
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All the time
Sometimes
Not often
Never
Do you have difficulty understanding what children are saying?
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Yes
No
Do you experience a ringing or buzzing sound in your ear(s)?
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Yes
No
Sometimes
When with a group of people, do you have difficulty following the conversation?
*
Yes
No
Submit
*Kaw Valley Hearing will be in contact with you within 24 hours (M-F) of submission of your questionairre to discuss the results.
