Characteristics Of Amplification Tool (Coat)
ADVERTISEMENT
1
2111 South Spruce Street Suite #102
Nazareth, PA 18064
Audiology Services LLC
Phone: 610-694-0141 Fax: 610-317-8483
E-Mail: audiologyservices@verizon.net
Web:
Characteristics of Amplification Tool (COAT)
Date: _____________________________________________
Name: _________________________________________________ Date of Birth __________________________________________________
Our goal is to maximize your ability to hear so that you can more easily communicate with others. In order to reach this Goal, it is
important that we understand your communications needs, your personal preference, and your expectations. By having a better
understanding of your needs, we can use our expertise to recommend the hearing aids that are most Appropriate for YOU. By working
together WE will find the best solution for you.
Please complete the following questions. Be honest as possible. Be as precise as possible. Thank You.
1.
Please list the top 3 situations where you would most like to hear well. Be as specific as possible.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2.
How important is it for you to hear well? Circle the number.
NOT very Important
1
2
3
4
5
6
7
8
9
10
VERY IMPORTANT
3.
How motivated are you to wear and use hearing aids? Circle the number.
NOT very Important
1
2
3
4
5
6
7
8
9
10
VERY IMPORTANT
4.
How well do you think hearing aids will improve your hearing? Circle the number.
I expect them to:
NOT be helpful at all
1
2
3
4
5
6
7
8
9
10
Greatly improve my hearing
5.
What is your most important consideration regarding hearing aids? Rank the order following factors with 1 as the most important and 4 as the
least important. Place an X on the line if the item as no importance at all:
_____
Hearing aid size and the ability of others not to see the hearing aids
_____
Improve the ability to hear and understand speech
_____
Improve ability to understand speech in noisy situations (e.g. restaurants, parties)
_____
Cost of the Hearing Aids
6.
Do you prefer hearing aids that: (Check One)
_____
are totally automatic so that you do not have to make any adjustments to them
_____
allow you to adjust the volume and change the listening programs as you see fit
_____
no preference
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical