Hearing Loss Eligibility Quiz
Take this quick quiz to find out if you may be eligible for hearing loss support or evaluation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Have you noticed any difficulty hearing conversations, especially in noisy environments?
*
Yes
No
Sometimes
How often do you ask people to repeat themselves?
*
Frequently
Occasionally
Rarely
Never
Do you experience ringing or buzzing in your ears (tinnitus)?
*
Yes
No
Please rate the impact of hearing difficulties on your daily life.
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Which of the following situations are challenging for you? (Select all that apply)
*
Talking on the phone
Watching TV
Group conversations
In noisy places (restaurants, parties, etc.)
None of the above
Do you have a family history of hearing loss?
*
Yes
No
Not sure
Have you been exposed to loud noises regularly (work, hobbies, music, etc.)?
*
Yes
No
Please indicate how frequently you experience the following symptoms:
*
Rows
Never
Sometimes
Often
Difficulty understanding speech
1
2
3
Turning up TV or radio volume
4
5
6
Missing doorbells or phone rings
7
8
9
Feeling isolated due to hearing issues
10
11
12
Would you like to be contacted for a free hearing assessment?
Yes, please contact me
No, thank you
Submit Quiz
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