Thank you for participating in this short survey, addressing the
vital issue of hearing loss and it’s impact on families and loved ones.
It will take no more than five minutes and all questions are multiple
choice answers.

1. What are your favourite leisure activities?

What are your favourite leisure activities? Dining out Cinema/theatre Music/radio Reading	Arts or Crafts Computer/internet Charity work Service clubs eg. Probus, Rotary, etc
Other (please specify)

2. How do you keep physically active?

How do you keep physically active? Walking Cycling Gym Dancing	Golf Bowls Fishing
Other (please specify)

3. Are you

Are you Male

Female

4. Which age bracket do you fall under?

Which age bracket do you fall under? Under 40 years

40 – 50 years

50 – 60 years

60 – 70 years

70 – 80 years

Over 80 years

5. How do you rate your hearing?

How do you rate your hearing? Good

Have some difficulty

Poor

1. Lifestyle

1. What are your favourite leisure activities?

2. How do you keep physically active?

3. Are you

4. Which age bracket do you fall under?

5. How do you rate your hearing?