Client Assessment Form

Part 1: To be completed by clinician (on paper or online)

1. Clinician ID # …………………..

2. Client ID# …………………...

3. Eligibility: DVA OHS Neither

4. SRTn: …………………….…. (dB) (if measured)

5. Air Conduction Thresholds (dB HL)

500 Hz 1000 Hz 2000 Hz 4000 Hz

Left HL

Right HL

6. Is the hearing loss:

Left ear Right ear

Primarily sensorineural

Primarily conductive

Markedly mixed (>15 dB ABG)

Please make your assessment of the client for the following three items based on their needs revealed in their history, and your observations of the client.

7. The primary need of this client is:

Listening where there is significant background noise, or

Listening where there is relatively little noise competition.

8. Overall cognitive functioning of the client

No problems

Slight problems

Minor problems

Moderate problems

Severe problems

Very severe problems

9. Manual dexterity

No difficulty Slight difficulty

Mild difficulty

Moderate difficulty

Severe difficulty

Very severe difficulty

Devices chosen (if proceeding with fitting)

Left Right

10. Manufacturer or brand

Model

11. Style

BTE RIC ITE ITC CIC Other

BTE RIC ITE ITC CIC Other

12. Mould / dome Open

Vented

Closed

Open

Vented

Closed

13. Process indicator (if applicable – usually not)

Process 1 Yes No

Process 2 Yes No

Process 3 Yes No Part 2, starting on the next page can be completed:

On paper by the client in the waiting room;

On paper by the clinician; or

Online by the clinician.

Client ID#: ……………

Part 2

Please answer the following questions.

14. How old are you: ……………… (years)

15. Postcode: ………………..

16. Gender: Female Male Other / Not disclosed

17. Did you attend today with a family member or close friend that you spend a lot of time

with: Yes No Please proceed to Question 19

18. If “Yes”, then please ask that person the following:

How do you feel about your family member / friend wearing hearing aids?

Not at all happy Slightly happy Moderately happy

Very happy

19. How many people do you live with? ………………..

20. In a typical week, approximately how many times do you have a conversation with people other than those you live with?

Less than 7 7 to 21 More than 21

21. Overall, how much difficulty do you have hearing (when not wearing hearing aids)?

No difficulty Slight difficulty

Moderate difficulty

Quite a lot of difficulty

Very much difficulty

22. How much difficulty do you have hearing one other person in a quiet place (when not wearing hearing aids)?

No difficulty Slight difficulty

Moderate difficulty

Quite a lot of difficulty

Very much difficulty

23. Did you come here today mostly because:

You wanted to, or

Someone else wanted you to.

24. Overall, how much are you bothered by ringing in your ears?

No ringing at all

Not at all bothered

Slightly bothered

Quite bothered

Very bothered

Extremely bothered

25. How well do you think you could manage hearing aid(s)?

Not at all Possibly can manage

Probably can manage

Easily manage Very easily manage

26. How interested are you in obtaining hearing aid(s)?

Not very interested

Slightly interested

Moderately interested

Quite interested

Very interested

27. How much benefit do you expect your hearing aid(s) will provide?

Not much benefit

Slight benefit

Moderate benefit

Quite a lot of benefit

Very much benefit

28. Have you ever tried hearing aids?

Yes No Proceed to Question 31.

29. If yes: For how long (approximately) have you worn hearing aids?

…………. Years, or

…………. Months, or

…………. Days

30. How satisfied were you with them?

Very dissatisfied

Dissatisfied

Neither satisfied nor dissatisfied

Satisfied Very satisfied

31. How did you choose your provider? (select all that apply)

Convenient Location

Advertising (media or letterbox)

Personal invitation from provider (mail or phone call)

Referral from GP or other health professional

Recommendation by a family member or friend

Listing provided by the Government

Other

32. There are more questions we would like to ask about you and your hearing. Would it be OK to mail some questions to you for you to return by pre-paid mail? We will randomly choose a small number of people amongst those agreeing.

Yes No