• Cochlear Implant Adult Questionnaire

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Living Situation*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is the best way to contact you during the day time? (Please be aware that we are unable to send texts) Work Phone, E-mail, Main Phone, Alt. Phone*
  • Employment*
  • Sign language interpreter needed:*
  • What is the highest level of education you have completed?*
  • Was the onset of your hearing loss*
  • Has your hearing loss changed over time?*
  • Did you lose your hearing in both ears at the same time?*
  • Is there one ear that is your "better hearing ear"?*
  • Do you know the cause of your hearing loss?*
  • If yes, please check all that apply:
  • Is there any hearing loss within your immediate or extended family?*
  • Have you had frequent exposure to any of the following? (Check all that apply_*
  • If yes, did you wear ear protection during this exposure?*
  • Did you serve in the military?*
  • Please indicate if you ever have experienced any ringing in the ears:*
  • Have you had any medical imaging of your ears or head?*
  • If yes, what type of imaging?*
  • Please describe below what kind(s) of amplification devices you have tried or currently use? (Please check all that apply):*
  • What is your preferred method of distance communication with friends and family?*
  • Are you able to understand spoken language via the telephone?
  • Have you ever used a FM system to understand speech in noise or at a distance?*
  • Have you ever used any other form of assisted listening devices? (i.e., amplified telephone, loop systems, etc)*
  • Have you ever used any type of alerting device for sounds you cannot hear?? Ii.e., visual door bell, vibrating alarm clock etc ):*
  • Have you ever been treated with the following:
  • Are you allergic to anything?*
  • Do you use a cane, walker, or wheelchair to get around?*
  • Have you ever been diagnosed with or treated for any of the following? (If the answer is no, please leave blank)*
  • Do you have vision loss?*
  • If yes, check all that apply below
  • Do you wear glasses?*
  • If yes, is your vision corrected to normal?

  • Understanding Your Needs and Concerns

    Your responses to the questions below will help us to get to know you and better understand your concerns. With whom do you spend most of your time?

  • Were you referred for this assessment?*

  • Speech Spatial Qualities (SSQ12)

    The following questions inquire about aspects of your ability and experiences hearing and listening in differnt situations. For each question, indicate anywhere on the 1-10 rating scale. Ten means you would be perfectly able to do or experience what is described and zero means you would be unable to do or experience what is described. If a question does not apply, leave it blank. 

  •
  • All cochlear implant recipients are able to understand speech at initial activation.*
  • Speech will sound natural to all cochlear implant recipients.*
  • Cochlear implant recipients no longer need to speech read/lip read.*
  • Cochlear implant recipients can understand speech in background noise easily.*
  • Television programs are easy to understand for cochlear implant recipients.*
  • Cochlear implant recipients report that music sounds natural.*
  • All cochlear implant recipients can determine the location of a sounds without visual cues.*
  • All cochlear implant recipients can communicate over the telephone.*
  • Insurance will cover all equipment costs.*
  • Cochlear implant recipients no longer have hearing loss.*
  • All cochlear implant recipients eventually have the same hearing abilities.*
  • Cochlear implant recipients will lose their natural hearing in the ear implanted after surgery.*
  • Recipient's outcomes are dependent on how much hearing loss they had prior to implantation.*
  • Recipient's outcomes are dependent on if they used a hearing aid prior to implantation.*
  • Recipient's outcomes are dependent on how much they use their devices.*
  • Please let us know if you would like more information or are interested in any of the following opportunities listed below:
  • Please complete and attach with this form:
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  • Documents can also be mailed to the following address: 

    Mailing Address:                                                                         Fax Number:                                                   Email: 

    Patient Services Coordinator                                          531-355-5028                                        CITeam@BoysTown.org 

    BTNRH/CCD-LLTC 

    555 N 30 Street 

    Omaha NE 68131

    If you have any questions, please call Patient Services Coordinator at 531-355-5698

  • For Office Use Only

    Reviewing Physician's Name: 

    Date Reviewed: 

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