top of page

PERSONALISED EAR HEALTH QUESTIONNAIRE

At Comforts Hearing, we understand the significance of personalised ear health questionnaires. Our tailored questionnaires are meticulously designed to gather detailed insights into your ear health, allowing our experienced professionals to gain a comprehensive understanding of your unique needs. By completing our questionnaire, you enable us to customise our services to address your specific requirements, ensuring that you receive individualised and professional care. Your ear health is our top priority, and we are committed to providing a thorough assessment to support your overall well-being.

COMFORTS HEARING

EAR HEALTH QUESTIONAIRE

Knowing more about your home life and occupation will help us advise you appropriatley:

Do you live:
Alone
With someone else
In a care home
Other

Your ears and hearing:

Have you had any sudden or rapid changes in your hearing (within 90 days)?
Yes
No
Does your hearing change on different days?
Yes
No
Do you get pain in your ears?
Yes
No
Do you get any infections or discharge from your ears (not including wax)?
Yes
No
Have you had ear-related problems?
Yes
No
Have you ever had a perforated eardrum?
Yes
No
Do you hear any rushing, hissing, ringing, beating, pulsing or any other noises in your ears is often called tinnitus?
Yes
No
Do you have a strong sensitivity to everyday loud sounds that do not bother other people?
Yes
No
Have you ever seen an Ear, Nose and Throat specialist for ear, hearing or dizziness problems?
Yes
No
Have you ever seen an Ear, Nose and Throat specialist for ear, hearing or dizziness problems?
Yes
No
Do you wear hearing aids?
Yes
No

Hearing difficulties:

Please click the boxes to select any of the situations in which you may find that your hearing affects you. If you feel no situations apply to you, please leave this section blank.

One-to-one conversation in quiet:
Yes
No
One-to-one conversation in noise:
Yes
No
Conversations in a group with no background noise:
Yes
No
Conversations in a group with background noise:
Yes
No
Hearing the television or radio at normal volume:
Yes
No
Hearing a familiar speaker on the telephone:
Yes
No
Hearing an unfamiliar speaker on the telephone:
Yes
No
Hearing the phone ring from another room:
Yes
No
Hearing the doorbell or knocker:
Yes
No
Hearing in church or a meeting:
Yes
No
Hearing traffic:
Yes
No
Hearing the fire alarm:
Yes
No
Decreased social contact:
Yes
No
Feeling embarrassed or stupid:
Yes
No
Feeling left out:
Yes
No
Feeling upset or angry:
Yes
No
Other:
Yes
No

Medical History (Please click 'Yes' or 'No' for each question.)

Do you experience any dizziness?
Yes
No
Have you ever been exposed to significant noise in your life?
Yes
No
Has anyone in your family had a hearing loss not associated with aging?
Yes
No
Do you have any skin allergies?
Yes
No
Do you have any altered sensation in your face, like numbness, tingling, or a droop?
Yes
No
Have you ever taken any medication that you were told may affect your hearing?
Yes
No
Have you had any head injuries or strokes?
Yes
No
Do you have problems with your eyesight (with or without glasses)?
Yes
No
Do you have problems lifting your hands to your ears?
Yes
No
Do you have difficulties with your memory?
Yes
No
Do you have a pacemaker, defibrillator or brain shunt fitted?
Yes
No
Referral required to GP?
Yes
No
bottom of page