Adult Case History & Profile

Basic Details
Chief Complaints
Hearing History
Listening Environments

How well do you hear in this environment?

Environment Well Fair Poor
One-to-One Conversations
Quiet Room (1 to 2 people)
Small Groups
Large Gatherings (4-6 people)
At the Workplace
Watching TV
At Religious Services
Meetings / Lectures
In the Car
Outdoors
On the Telephone

How frequently are you in this environment?

Environment Often Sometimes Rarely
One-to-One Conversations
Quiet Room (1 to 2 people)
Small Groups
Large Gatherings (4-6 people)
At the Workplace
Watching TV
At Religious Services
Meetings / Lectures
In the Car
Outdoors
On the Telephone
Priorities and Motivation

Please rank the following in terms of importance to you (1 being most important).