Pre Hearing Assessment Questionnaire

Name

First

Last

Address

Date of Birth

Phone number & Email Address

How long have you had difficulties with your hearing?

Have you had any recent or regular earache or ear infections?

Yes/No If yes, please provide details

Do you get noises in your head or ears (tinnitus) which last longer than 5 minutes?

Yes/No If yes, please provide details

Have you had any exposure to loud noise within the last 24 hours?

Yes/No If yes, please provide details

Do you suffer from vertigo or dizziness?

Yes/No If yes, please provide details

Do you have any implantable devices such as a programmable ventriculoperitoneal (PVP) shunt?

Yes/No If yes, please provide details

How shunt? main

Please list your main priority areas for improvement with your hearing

Get in touch with Chester Hearing & Balance Services today for expert hearing solutions.

Independent Hearing Service Provider