Aural rehabilitation survey tool to be utilized with patients in Audiology practices after initial hearing aid fitting appointments.

1. 1
First Hearing Aid Check Up – Patient Survey
2021 Aural Rehabilitation Tool Created by Abby Malawer, Au.D., CCC-A
How was your Hearing Aid Fitting (HAF) Experience?
Our company is committed to providing you with the best hearing healthcare experience possible, so your comments
are welcome as we continue to grow and improve upon our clinical services. Please fill out this questionnaire for your
Audiologist to review. Thank you.
Please rate the overall quality of your hearing aid evaluation and fitting appointments.
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
Disappointing Exceptional
Did you leave your HAF appointment feeling confident that your hearing aids are a secure and comfortable physical
fit?
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
No, Not Quite Absolute Yes
Did your Audiologist/hearing care professional review…
Take-home instructions for continued practice on placement and use? ¨ Yes | ¨ No
How to clean the hearing aids and change the wax guards? ¨ Yes | ¨ No
How to change the battery or re-charge your hearing aids? ¨ Yes | ¨ No
If you are receiving the help of a caregiver, was that person adequately involved in the fitting process?
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
Not yet Yes, the communication was great
First time hearing aid users gradually transition from softer levels of amplification to prescribed gains based on
hearing loss severity. Was this process explained?
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
Not at all Very clearly
Describe your enthusiasm surrounding wearing hearing aids since the fitting appointment
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
Still hesitant about use Increasingly excited and motivated to wear
Do you feel you had professional guidance towards selecting appropriate hearing aid devices and a warranty
package that matched your budget?
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
No Somewhat Yes
How frequently would you like to hear from your Audiologist/hearing care professional?
¨ every few months ¨ once every 6 months
¨ once a year ¨ never - I will do the contacting
Do you prefer to be in touch via phone or e-mail? Circle one. ________________________________________________

2. 2
Do you use a smartphone?
¨ Yes | ¨ No
Android or iPhone? Circle one.
If yes, were your hearing devices paired with your smartphone at the fitting appointment?
¨ Yes | ¨ No
If not, please explain why this connectivity was not reviewed (hearing aids do not have Bluetooth, etc.).
If applicable, what is your level of comfort with your smartphone?
¨ comfortable for all functions (apps, calls, texts, and emails) ¨ use it sparingly, but I know how
¨ can only use with outside help ¨ I don’t have a smartphone
Select any hearing aid features you might be interested in…
¨ direct streaming for phone, audio, and music ¨ television streaming
¨ communication partner or FM microphone ¨ rechargeable travel cases
¨ noise program for tinnitus management ¨ telecoil hearing loop
Rate your confidence in following instructions for use of additional accessory devices and/or remote programming
¨ 1 ¨ 2 ¨ 3 ¨ 4 ¨ 5
Not confident Very Confident
Do you feel you need additional in-person visits to adjust programming or are you open to learning about remote
programming options and virtual visits if your hearing aids are Bluetooth-capable? Please explain.
If you could share one piece of advice to improve the first fitting experience for future patients, what would that
be?