Your name

Your email

Contact Number

Date

Time 08:0009:0010:0011:0012:0013:0014:0015:0016:00

How is your hearing

Do you have a good / bad ear GoodBad

Do you have any ringing or buzzing noise in your ears. YesNo

Do you sometimes feel dizzy or like the room is spinning. YesNo

Have you had a hearing Aid before YesNo

Can you hold a conversation with 2 / 3 people YesNo

Do you feel isolated by the hearing loss YesNo

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