Questionnaire for New ALD Wearer
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Please provide us with the following information
1. Do you have a hearing aid? _________________
2. Do you wear your hearing aid? _______________________
3. Does your hearing aid have a telephone switch (T-Coil)? ________
4. Do you have a smoke detector in your home? _____________
5. Can you hear the fire alarm without your hearing aid, or do you
need
help from someone to alert you? ___________________________
6. Are you able to hear if someone is at your door? ________________
Do you need something to alert you to the doorbell ringing? _________
7. Can you hear the telephone ring? ________________
8. Do you need an alarm clock to wake you up? __________
9. Where do you have trouble hearing?
a. Restaurants: ___________
b. b. Phone: _____________
c. TV: _____________
d. Car: __________________
e. Other: _________________
Name:_________________________________
Phone #: _________________
Address: ______________________________________________
Email: ________________________________________________
Are you a member of SHHH-Peninsula (Self Help for Hard of
Hearing)?_____
Would you like information about Self Help for Hard of Hearing
(SHHH)? ______________
This information will not be shared outside of this program The
information given will be used to build a foundation to expedite this
service to Hard of Hearing people
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