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Hearing Stage Tool | Post Appointment

Post Appointment Questionnaire

What stage of hearing loss are you at?

Thank you again for completing the pre-appointment portion of the Hearing Stages Tool Questionnaire before your recent hearing appointment with Lions Hearing Clinic.

The questions below form the brief post-appointment portion of the Hearing Stages Tool Questionnaire, which you have previously consented to complete.

Please read the participant information sheet before completing the survey.

If you have any further questions concerning this pilot study, please do not hesitate to contact Dr Cathy Sucher at cathy.sucher@earscience.org.au.

The survey will take about 4 minutes to complete.

"*" indicates required fields

1. What is your name?*

First Last

2. What is your date of birth?*

DD slash MM slash YYYY

3. When you had your hearing appointment with your audiologist, did you discuss the hearing stages tool, or your hearing stage, with them?*

Yes

No

4. Who started the conversation about your hearing stage?*

Me

My loved one

My audiologist

5. Please tick the items from the hearing stages tool that you discussed (Please tick all appropriate options)*

What hearing stage I thought I was at

What hearing stage my loved one thought I was at

What hearing stage my clinician thought I was at

My hearing test results in relation to the tool

My speech test results in relation to the tool

The management options (e.g. hearing aids, cochlear implants etc) that may be appropriate for me

The link or QR code to other information about management options

6. Which hearing loss management options did you know about before you used the Hearing Stages Tool (Please tick all appropriate options)*

Hearables

Prescription hearing aid

Bone conduction/Middle ear implant

Cochlear implant

Combination of a hearing aid and a cochlear implant

Assistive Listening Devices

None of the above

Other (please indicate)

Other

7. Did your hearing loss management plan change after using the tool in clinic?*

Yes

No

8. Please indicate how your hearing loss management plan changed (Please tick all appropriate options)

I’m considering an assistive listening device

I’m considering a hearable device

I’m considering a prescription hearing aid

I will be attending a hearing implant information session

I will be/have looked at a website with more information about the different hearing management options

I have/will be discussing hearing implants with a hearing implant mentor/user organised by the clinic

I have been referred for a bone conduction/middle ear implant assessment

I have been referred for a cochlear implant

Other (please state)

Other

9. If you are considering a hearing implant (cochlear implant, middle ear implant or bone conduction implant) is there anything that is stopping you from having an implant assessment? (Please tick all appropriate options)*

The referral process seems complicated

I have to go to another clinic for the implant assessment

I am worried about the surgery

I am worried about the possible risks involved in getting an implant

I am worried how much an implant will cost me

I am unsure what benefit I will get from an implant

I am not healthy enough for surgery

I am too old for surgery

I am too old to get used to an implant

My hearing isn’t bad enough for an implant

I am unable to get to the appointment by myself

I want a support person to go with me to the appointment but they aren’t available

Not considering an implant

Other (please state)

Other

10. Are you interested in finding out more about the outcomes of this research*

Yes

No

11. Are you happy to be interviewed (online/over the phone or in person) about your experiences using the Hearing Stages Tool?

Yes

No

12. Would your loved one be happy to be interviewed (online/over the phone or in person) about their experiences using the Hearing Stages Tool?

Yes (please provide contact details)

No

Name

First Last

Phone

Email

Phone

This field is for validation purposes and should be left unchanged.

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First Last

Email*

Email

This field is for validation purposes and should be left unchanged.

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