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Assessment Survey
First Name
*
Last Name
*
Email
*
Phone
*
Have you ever had ear surgery or an eardrum perforation?
*
Choose a response...
Yes - in the last 5 years
Yes - but over 5 years ago
No, never
Is there a large difference in hearing between your left and right ear? (Hearing asymmetry)
*
Choose a response...
Yes - I have hearing asymmetry
No/minimal asymmetry
Have you worn hearing aids before? If so, were these hearing aids molded to custom fit your ear?
*
Choose a response...
No - I have never worn hearing aids
Yes - with molds
Yes - without molds
Do you experience a ringing in your ears (tinnitus)?
*
Choose a response...
Yes
No
Order Number
*
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