Complete
the questionnaire and address form then click
on the 'submit' button (click reset to clear and start again)
Questions
Yes
No
Do
your family and friends complain that your T.V.
volume is too high for their listening comfort?
Do
you often ask people to repeat themselves?
Do
you feel that other people mumble?
Do
you have trouble understanding a conversation when
there is background noise or when people are all
talking at the same time?
Have
your family or friends ever suggested that you have
a hearing problem?
Do
you avoid going to parties and social events, because
there is too much noise, which makes it difficult
for you to hear what is being said?
Do
you misunderstand what is being said, when in a
restaurant or in a car?
Are
young children's voices particularly difficult to
understand?
Do
you need to sit close to the speaker when in a meeting
or at church?
Do
you feel it is easier to hear when you look directly
at the person who is talking?
Do
you find it difficult to locate where a sound is
coming from?
Answering YES to one or more of these questions, does not indicate that you have a hearing problem, however we would suggest that you contact us and we can arrange for you to have a Hearing Health check up, completely free of charge. Please fill in your details below and click on submit. We will then contact you to arrange for this Free service to be provided.
Name
Address
Eve. Tel.
No.
Day Tel.
No.
E-mail address
Florida Hearing Aid Systems
SarasotaHearingAids.com
