Hearing Aid / Device Satisfaction Survey
EARtrak is interested in your hearing care experience as a consumer. We would like your opinions about the quality of service, and the performance of your most recently fitted hearing aid/device(s). To obtain your opinion, we would like you to complete the EARtrak survey below. Please be assured that all surveys are confidential, and that your personal information has remained with us unless you choose to have this forwarded to your service provider.
Name
Which clinic fitted your hearing aid/device?
Your email address
A few questions about you


Age (years)
                                       
Country
About your hearing aid / device


Do you wear a Hearing Aid/Device


How was your Hearing Aid/device paid for?





What style of Hearing Aid/device do you wear in the left ear?
Left Ear
What style of Hearing Aid/device do you wear in the right ear?
Right Ear
Manufacturer left ear
Manufacturer right ear
Model left ear
Model right ear
Age of Hearing aid/device (years) left ear
Age of Hearing aid/device (years) right ear
If you have been invited by your service provider to complete an EARtrak survey online, please enter the Practice Number and Client Number from your invitation.
Practice#
Client Number
Client#
Please rate your degree of difficulty when you are not wearing a hearing aid/device (please mark one box)
                   
Over the last 2 weeks, how many hours on average did you use your hearing aid/device?





Think about the situations where you most wanted to hear better, before you got your present hearing aid/device(s). Over the past two weeks, how much has the hearing aid/device helped in that situation? (Please mark one box)





Think again about the situation where you most wanted to hear better. When you use your present hearing aid/device(s), how much difficulty do you STILL have in that situation?





Considering everything, do you think your present hearing aid/device(s) worth the trouble?





Over the past two weeks, with your present hearing aid/device(s), how much have your hearing difficulties affected the things you do?





Over the past two weeks, with your present hearing aid/device(s), how much do you think other people were bothered by your hearing difficulties?





Considering everything, how much has your present hearing aid/device(s) changed your enjoyment of life ?
                   
Overall, how satisfied are you with your hearing aid/device(s)?
                   
Would you recommend hearing aids/devices to a friend or family member with a hearing problem?
           
Would you recommend your hearing service provider to a friend or relative with a hearing problem?
           
How did you learn about your hearing service provider?










How did you learn about your hearing service provider - Other, please specify.
Listed below are some listening situations. Please mark how satisfied you are with your current hearing aid/device(s) for each situation. (Mark one box on each line). The term ‘neutral’ means neither satisfied nor dissatisfied.
conversation with one person
                       
in small groups
                       
in large groups
                       
outdoors
                       
concert/movie
                       
place of worship /lectures
                       
watching TV
                       
in a car
                       
workplace
                       
telephone
                       
restaurant
                       
If you would like to make any comments about listening with your hearing aid/device(s), please write them here.
Listed below are some hearing aid/device features. For each feature, please mark one box to show how satisfied you are with that feature. (Mark one box on each line.) The term ‘neutral’ means neither satisfied nor dissatisfied.
overall fit/comfort
                       
ease of adjusting volume
                       
visibility of hearing aid
                       
frequency of cleaning required
                       
ongoing expense (eg. batteries, maintenance)
                       
battery life
                       
reliability
                       
clarity of tone and sound
                       
sound of own voice
                       
ability to tell location of sounds
                       
comfort with loud sounds
                       
whistling/feedback /buzzing
                       
If you have any comments about your hearing aid/device(s), please write them here.
Listed below are some features of your hearing service provider. For each service feature please mark one box to show how satisfied you are. (Mark one box on each line). The term ‘neutral’ means neither satisfied nor dissatisfied.
Professionalism of clinician
                   
Friendliness of Office staff
                   
Patience of clinician
                   
Explanations given to you
                   
Amount of time spent with you
                   
Cleanliness and appearance of the office
                   
Quality of service after purchase
                   
Clinician understood my needs
                   
If you have any comments about the service you’ve experienced, please write them here
Do you permit us to send your comments directly to your service provider?
       
Name, Address & email of your hearing clinic
Do you want to be contacted by your service provider?



Genuine Opinion
* I certify that this review is my genuine opinion of my hearing care experience, and that I have no personal or business affiliation with this establishment, and have not been offered any incentive or payment originating from the establishment to write this review.
EARtrak - Independent Measurement of Hearing Aid Outcomes