Name

Number

Email Address

Age

Physical Home Address (EG. 1236 Park Street, Brooklyn, Pretoria 0081)

Select Your Closest Branch Select Your Closest BranchBenoniPotchefstroomPretoria East (Newlands)Pretoria East (Willows Crossing)Kensington JHBKempton ParkBoksburgRoodepoortVanderbijlpark

Do you have Medical Aid? Do you have Medical Aid?Yes I do.No I don't.

Have you worn a Hearing Aid before? Have you worn a Hearing Aid before?Yes.No.I am currently wearing one.

Did your hearing loss happen gradually? Did your hearing loss happen gradually? Yes No Not sure

Is your hearing loss in one or both ears? Is your hearing loss in one or both ears? Left ear Right ear In both ears

Do you experience ear ache? Do you experience ear ache? Yes No Periodically (Sometimes)

Do you experience headaches? Do you experience headaches? Yes No Periodically (Sometimes)

Do you experience any discharge from the ear? Do you experience any discharge from the ear? Yes No Periodically (Sometimes)

Do you experience any dizziness? Do you experience any dizziness? Yes No Periodically (Sometimes)

Do you experience any Tinnitus (ringing ears)? Do you experience any Tinnitus (ringing ears)? Yes No Periodically (Sometimes)

Do you have any current ear infections? Do you have any current ear infections? Yes No Periodically (Sometimes)

Do you have any deafness in the family? Do you have any deafness in the family? Yes No Not sure

Are/were you exposed to any loud sounds? Are/were you exposed to any loud sounds? Yes No Not sure

How would you describe your hearing on the phone? How would you describe your hearing on the phone? Good Bad Reasonable

Do you get your words mixed up, or hear words wrong? Do you get your words mixed up, or hear words wrong? Yes No Periodically (Sometimes)

Do you battle to hear in crowds, or with background noise? Do you battle to hear in crowds, or with background noise? Yes No Periodically (Sometimes)

Do loud sounds bother you? Do loud sounds bother you? Yes No Periodically (Sometimes)