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