Forms

Please print and fill out the forms below.

Intake Sheet
Adult Case History
Child Case History

Small Medium Large

Contact Us

Find out what our hearing professionals can do to treat your hearing loss!

Schedule Now

Guide to Hearing Aids

Make informed decisions on the purchase of your next hearing aid device!

Download Now

Hearing Survey

Take our hearing health survey and start your journey to better hearing!

Start Survey

Click here to begin our Online Hearing Survey.

Hearing Survey

Please answer the question below to the best of your ability. After you choose your answer, the next question will appear. At the end of the survey, you will be provided with a score, and you may send this score to us so we may discuss any hearing loss issues you are having.

Are there situations in which you find it difficult to hear clearly?

Do you have to strain to understand conversations?

Do you have a problem hearing over the telephone?

Do you have trouble following a conversation when two or more people are talking at the same time?

Do you have trouble hearing conversations in a noisy background such as a restaurant or a group gathering?

Do you have dizziness, pain, or ringing in your ears?

Do family members or coworkers remark about you missing what has been said?

Do people complain that you turn the TV volume up too high?

Do you find it hard to hear someone when they talk in a soft voice or whisper?

Do you find understanding women and children particularly challenging?

Almost Always Half the Time Occasionally Never

You received a score of

You are not experiencing common signs of hearing loss. However, if you suspect you may have hearing loss or are experiencing other symptoms not listed here, please contact our office for a consultation.

It appears you may be experiencing signs of a hearing loss. A hearing test can help detect early signs. We recommend contacting our office to schedule a hearing test.

Your responses indicate that you are experiencing common signs of a hearing loss. We recommend that you contact us to set up an appointment for a hearing test.

You are experiencing many signs of a hearing loss. It is highly recommended that you contact our office today for an appointment to meet with a hearing professional.

Check this box to verify you're a human.

Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

Factoria Hearing Center

Navigation

Forms