Hearing Quiz Order Number First Name * Last Name * Email Address * How did you hear about us? * Doctor Referral Otolaryngology Associates Family Member or Friend Search Engine Facebook Hearing Aid Manufacturers Website Advertisement Others Hearing Loss Quiz Does a hearing problem cause you difficulty when listening to TV or radio? * Often Sometimes Never Do you feel handicapped by a hearing problem? * Often Sometimes Never Does a hearing problem cause you to attend religious services less often than you would like? * Often Sometimes Never Does a hearing problem cause you to feel embarrassed when you meet new people? * Often Sometimes Never Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? * Often Sometimes Never Do you feel that any difficulty with your hearing limits or hampers your personal or social life? * Often Sometimes Never Does a hearing problem cause you to have arguments with family members? * Often Sometimes Never Do you have difficulty hearing when someone speaks in a whisper? * Often Sometimes Never Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? * Often Sometimes Never Does a hearing problem cause you to feel frustrated when talking to members of your family? * Often Sometimes Never Are you interested in having one of our local Audiologist contact you? * Yes No Choose a Whisper location closest to you * Avon Carmel (Main North Office) Greencastle Greenfield Greenwood Indy – Downtown Indy – Nora Indy – Northeast Indy – South Kokomo Mooresville Noblesville Shelbyville Score Score:
