A Needs Assessment is a method of judging one's need for a particular service or product. In this case, a "Hearing Needs Assessment" is a method of judging one's need for amplification based on self report. On arrival at the clinic you will be asked to complete a "Hearing Needs Assessment" such as the one below. If you like, print off the form below, complete it and bring it with you to your appointment.
Name: ______________________________________________________________________ Date: _________________________
1. What motivated you to come in today? _______________________________________________________________________________
_____________________________________________________________________________________________________________________
2. Please check the box which corresponds to your ability to hear in the situations listed and check how often you are in that situation.
Listening situation
How well do you hear
in this situation?
How often are you
poor
fair
good
rarely
sometimes
often
Quiet Room (1 to 2 people)
Restaurants
Car
Television
Church
Meetings/Lectures
Work Place
Telephone
Large Social Gatherings
3. What is your hearing aid experience?
A.
I have a hearing device and use it regularly on the ___right ear ___left ear.
B.
I have a hearing device, but don’t use it, or use it only occasionally.
C.
I tried a hearing device, but returned it for credit.
D.
I have inquired about hearing devices at another office(s), but did not purchase at that time.
E.
I have never used a hearing device.
4. Place a “1” before the item that is the most important to you in purchasing a hearing device.
Now, place “2” before the second most important thing to you when purchasing a hearing device.
Now, place a “3” before the third most important thing to you when purchasing a hearing device.
Lastly, put a “4” before the least important thing to you when purchasing a hearing device.
Sound Quality & Clarity
Durability/Reliability
Cost
Appearance
(Have you used a 1 and a 2 and a 3 and a 4)
5. On a scale of 1-10, where do you feel that you are (psychologically, emotionally, financially, etc.) regarding doing something about your hearing loss? (Please circle one)
1
2
3
4
5
6
7
8
9
10
Not motivated
Very motivated