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Patient Satisfaction Survey
Which office do you visit for your hearing care?
Which Audiologist/dispenser do you work with?
How did you learn of our practice? (Please check all that apply)
Friend or relative
Physician
Website
Newspaper ad
Yellow Pages
Received phone call
Health Fair
Received mail
Other
Please rate the answers that come closest to your everyday experience. If you have not experienced the situation we describe, try to think of a similar situation you have been in and respond for that situation. If you have no idea, bypass the question.
1…Almost always
2…Generally
3…Occasionally
4…Seldom
5…Never
1
2
3
4
5
Overall, I have been satisfied with the improvement in my hearing with my hearing aids…
With my new hearing aids I hear and understand conversation with my family better than before.
I can follow the conversation in a restaurant better than I could before…
When I am in a small room, I no longer have to struggle to hear and understand questions…
I was pleased with the service I received at my local office…
When I have a conversation with a friend, I have much less difficulty understanding what is said
My local office is within easy driving distance and easily accessible
I can hear and understand the news on the car radio
Running water sounds, such as water faucet, are comfortably loud…
I was happy with the thoroughness of my hearing testing
My hearing aids adjust well from soft to loud sounds
With my new hearing aids I hear and understand conversation with my family better than before.
At church services, the organ is comfortably loud
My hearing specialist is knowledgeable about my hearing needs
The office facilities are neat and adequate
I feel that my hearing specialist has my best interests and hearing needs at hear
I can communicate with others in a restaurant or crowd
I can follow the sermon at my church without straining
I can better follow the dialogue in a movie
I use the free service appointments as prescribed by my hearing health professional
How could we serve you better?
If you have been pleased with our service, would you please refer us to a friend or family member who could benefit from a hearing screening and consultation?
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