Hearing Test COSI - Explore Hearing

First Name

Doctors Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Last Name

Doctors Surgery

Email *

Whose idea was it to get the hearing test?

Did you bring someone with you today?

Who did you bring?

Would you like someone with you today?

No i am happy to contiinue
Yes please can we rearrange

Have you had your hearing tested before?

How long ago was your last hearing test?

Where did you have your last hearing test

Is there any one in your family with hearing difficulties?

Please tell us who.

Have you ever been around very loud noise for long duration's?

Including: Work, shooting, Motorsport etc

How concerned are you about you hearing?

The higher the number the more concerned you feel. Please move the slider to where you feel you are.

Have you worn hearing aids before?

What type are they?

What did you like about you current hearing aids?

How long have you had them?

What would you change about your hearing aids

If you need hearing aids are you willing to try them?

Why not?

Please select the areas you find difficult to hear in

TV
Radio
Music
Conversation (one to one)
Conversation (groups)
Cafe
Pub
Restaurant
Telephone
Work
Meetings
Talks/Lectures
Cars
Public transport
Shops
Banks
Place of worship
Outdoors

Please tell us the three most important places you would like to hear better in.

1. Most important place to hear better

3. Important place to hear better

2. Very important place to hear better

Any additional areas to improve

Have you had any pain lasting longer than 7 days in either ear in the last 90 days?

Do you suffer with rotational vertigo?

Do you feel the tinnitus is very distressing?

Do you feel your tinnitus matches your pulse?

Who have you seen about your tinnitus?

Have you had any discharge other than wax in the last 90 days?

Do you suffer with tinnitus?

Which ear?

Left
Right
Both
Unsure

Have you seen anyone about your tinnitus

Has your hearing suddenly dropped within the last 24 hours?

Do you have any facial numbness or weakness?

Do you feel you hearing has become considerably worse within the last 90 days?

Do you wear a pacemaker or defibrillator?

Have you been around any, very loud noise in the last 24 hours?

What did you have done?

Are you diabetic?

have you had any recent surgery or treatments on your ears?

Are you taking any blood thinning medication?

Are you taking any other medication

Otoscopy

Left Ear

Right Ear