Fisher's Auditory Problem Checklist - Syracuse Hearing Solutions

All hearing aids are different. It may be confusing to receive so many ads about many different hearing aids from many different hearing aid companies. There are so many different opinions on hearing aids that it makes it difficult to know what would be right for you. Are you concerned about investing in a hearing aid that may work for someone else, but may not work for you? Your hearing needs may be very different from someone else’s needs and we take that into consideration when helping you choose a hearing aid.

We carry most major manufacturers brands of hearing aids and have experience fitting over hundreds of different models of hearing aids.

Our Doctors of Audiology have the expertise to help you find the right hearing aid for you based on your hearing test results and your answers to the following questions…

Please attach your hearing test results and fill out the questionnaire so we can determine which hearing aid may be best for you.

Do you feel that you can hear but you can’t understand?

All the time Most of the time Some of the time None of the time

Do you feel that you rely on reading lips or seeing the speaker’s face in order to hear?

All the time Most of the time Some of the time None of the time

Are you sensitive to certain sounds?

Yes No Sometimes

Do certain sounds bother you?

Yes No Sometimes

Do certain voices bother you?

Yes No Sometimes

Which voices are most difficult to understand?

Male Female Child All of the above None of the above

Do you feel that you need to hear better..

All the time Most of the time Some of the time None of the time

Do family members and friends complain you can’t hear them?

All the time Most of the time Some of the time None of the time

Are you outdoors a lot?

Yes No Sometimes

Are you in loud surroundings?

All the time Most of the time Some of the time None of the time

Can you handle small batteries?

Yes No Sometimes

How would you consider your manual dexterity?

Excellent Good Fair Poor Unsure

Have you been told you have small ear canals in the past?

Yes No Unsure

Are you prone to sweating?

Yes No Sometimes

Do you feel you would have trouble putting a hearing aid on…

in your ear behind your ear both no trouble at all

Have you been told that you produce a lot of earwax?

Yes No Unsure

Do you consider yourself tech-savy?

Yes No Maybe Unsure

Do you have a smartphone?

Yes No Don't know what that is

Do you know about Bluetooth?

Yes No Somewhat Unsure

Would you be afraid of losing your hearing aids and want a way to track them with your phone?

Yes No Unsure

Would you like the ability to hear television, music, sound, directed wirelessly through your hearing aids?

Yes No Maybe Unsure

Do you feel that your lifestyle is..

Very active and attend varying social situations

Somewhat socially active, going out to social occasions sometimes

Mostly quiet lifestyle

Indoors and in quiet all of the time

What level of hearing aid technology are you most likely to consider?

I want the best of the best technology for me

I don’t feel I need the best, but I don’t want to be unhappy if I go for less

I would like to hear better, but I am on a strict budget

If you answered yes to one or more of the previous questions, you should have a complete hearing evaluation performed by our audiologist

Finish the form below and a specialist will be in touch to set up your appointment.

Please choose, YES or NO before each item that is/isn't considered to be a concern by the observer:

Has a history of hearing loss?

Yes

Has a history of ear infection(s)?

Yes

Does not pay attention (listen) to instruction 50% or more of the time?

Yes

Does not listen carefully to directions – often necessary to repeat instructions?

Yes

Says “Huh?” and “What?” at least five or more times per day?

Yes

Cannot attend to auditory stimuli for more than a few seconds?

Yes

Has a short attention span?

Yes

If you chose YES for 'short attention span,' please check the most appropriate time frame:

0-2 minutes

5-15 minutes

2-5 minutes

15-30 minutes

Daydreams – attention drifts – not with it at times?

Yes

Is easily distracted by background sound(s)?

Yes

Has difficulty with phonics?

Yes

Experiences problems with sound discrimination?

Yes

Forgets what is said in a few minutes?

Yes

Does not remember simple routine things from day-to-day?

Yes

Displays problems recalling what was heard last week, month, year?

Yes

Has difficulty recalling sequence that has been heard?

Yes

Experiences difficulty following auditory directions?

Yes

Frequently misunderstands what is said?

Yes

Does not comprehend many words/verbal concepts for age/grade level?

Yes

Learns poorly through the auditory channel?

Yes

Has a language problem, (morphology, syntax, vocabulary, phonology)?

Yes

Has an articulation (phonology) problem?

Yes

Cannot always relate what is heard to what is seen?

Yes

Lacks motivation to learn?

Yes

Displays slow or delayed responses to verbal stimuli?

Yes

Demonstrates below average performance in one or more academic areas?

Yes

Scoring: Four percent credit for each numbered item checked 'No'?

Number of items checked 'No'___ x 4 = ___

Fisher’s Auditory Problem Checklist

Please choose, YES or NO before each item that is/isn't considered to be a concern by the observer:

Scoring: Four percent credit for each numbered item checked 'No'?

Free Hearing Screening