Hearing Health Survey - Rochester Hearing & Speech Center
1.
How important is your hearing health relative to other areas of your health like vision and dental care?
Extremely important
Very important
Somewhat important
Not so important
Not at all important
2.
Have friends or family ever suggested that you get your hearing tested?
Yes
No
3.
Have you had a hearing test in the last five years?
Yes
No
4.
If you've had a hearing test, please indicate where:
With my Primary Care Physician.
I had my hearing tested at a free community screening event
I had my hearing tested at Rochester Hearing & Speech Center.
I had my hearing tested with another hearing health provider.
5.
Were you diagnosed with hearing loss?
Yes
No
6.
Do you use a hearing instrument?
Yes
No
7.
What type of insurance do you have?
Private insurance
Medicaid/Medicare
No insurance
8.
Do you experience any of the following challenges securing hearing health care? (Select all that apply.)
I am not able to find a hearing health provider that accepts Medicaid/Medicare.
My work schedule makes it difficult to schedule medical appointments.
I do not have transportation.
My insurance does not cover/fully cover my hearing health needs and I cannot afford the cost of treatment or a listening device.
None of the above
Other (please specify)
9.
Please indicate your age:
18-24
25-34
35-44
45-54
55-64
65+
10.
Please indicate your employment status:
Full-time
Part-time
Seasonal
Unemployed / Not in Workforce
Retired