Hearing Stage Tool | Pre Appointment

Pre Appointment Questionnaire

What stage of hearing loss are you at?

Adults with hearing loss are not always aware of all the options that may be available to help optimise their hearing.

We are conducting a pilot study of a tool to be used by adults with hearing loss, their significant others, and their hearing healthcare clinicians to improve awareness and discussion about the different management options that may be available for their hearing. This questionnaire is to understand the usefulness of this tool. The tool is included in this questionnaire and has also been sent to you by your hearing aid clinic as an email attachment so that you can print it out if needed.

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 7 minutes to complete and needs to be completed on a computer and not a mobile device.

Please click on the link below to open the Hearing Stages Tool for you to refer to for questions 17 to 25.

HEARING STAGES TOOL

"*" indicates required fields

Consent Statement

I have read the information provided and my questions, if I have any, have been answered to my satisfaction. I agree to participate in this research project, realising that I may withdraw at any time without reason and that this will not affect my relationship with my Hearing Clinic.

1. I agree to participate in this study?*

Yes

2. I agree to allow researchers to access my hearing assessment results from my Lions Hearing Clinic?*

Yes

About you

3. What is your name?*

First Last

4. What is your date of birth?*

DD slash MM slash YYYY

5. What is your Gender?*

Male

Female

Non-Binary or Third Gender

Prefer not to say

6. My English language reading ability is:*

Very poor

Poor

Fair

Good

Very good

Your Hearing

7. What hearing management option/s do you use for your RIGHT EAR?*

Hearables

Prescription hearing aid

Bone conduction/Middle ear implant

Cochlear implant

Assistive Listening Devices

None of the above

Other (please state)

Other

8. What hearing management option/s do you use for your LEFT EAR?*

Hearables

Prescription hearing aid

Bone conduction/Middle ear implant

Cochlear implant

Assistive Listening Devices

None of the above

Other (please state)

Other

9. When is your next hearing aid appointment with Lions Hearing Clinic?*

DD slash MM slash YYYY

Digital technology and the internet

10. I use the following devices at least once a week; (Please tick all appropriate options);*

Desktop computer

Laptop computer

Tablet/iPad (Mobile Device)

Smartphone (Mobile Device

11. I use the internet*

Daily

Weekly

Monthly

Never

12. I use the internet for (please tick all appropriate answers)*

Medical information

General information

Entertainment

Other (please state)

Other

13. How would you rate your skill level with a computer?*

Never used

Beginner

Competent

14. How would you rate your skill level with a mobile device (tablet/smartphone)?*

Never used

Beginner

Competent

15. How confident are you with a computer?*

Not confident at all

I usually need help

It depends on the task

Confident

16. How confident are you with a mobile device (tablet/smartphone)?*

Not confident at all

I usually need help

It depends on the task

Confident

Hearing Stages Tool

Click this link to open the Hearing Stages Tool before you begin this section | Hearing Stages Tool

17. Please look at the Hearing Stages Tool then click and drag the vertical bar below to the hearing stage you think you're at:*

18. If applicable, what hearing stage does your significant other, think you're at? Click and drag the vertical bar below.

0.0

0.1

0.2

1.0

1.1

1.2

2.0

2.1

2.2

3.0

3.1

3.2

4.0

4.1

4.2

Stage 0

Stage 1

Stage 2

Stage 3

Stage 4

You don’t have any noticeable problems with your hearing; you are able to have day-to-day conversations and can hear whispering from 1.5 metres away.

One-on-one conversations are probably fine but you may have difficulty understanding some words when there’s a lot of background noise.

You may have difficulty understanding everyday speech.
You may be unable to hear the doorbell or a telephone ringing. Also, it can be hard to follow or hear sounds during everyday conversations.

You have difficulty following a conversation without wearing a hearing device.
It is almost impossible to understand everyday conversations when you are not wearing a hearing device.

Using a hearing aid is most effective. Your hearing loss makes it difficult to even hear loud sounds, such as aeroplane engines or fire alarms.
You cannot hear at all and usually rely on lip-reading, gesture or other visual cues.

Cochlear Implants

Prescription Hearing Aids

Combination of Hearing Aid

& Cochlear Implant

Bone Conduction and Middle Ear Implants

Over the counter hearables

Assistive Listening Devices

Normal Hearing

Mild Hearing Loss

Moderate to Moderately Severe Hearing Loss

Moderately Severe to Severe Hearing Loss

Profound Hearing Loss

90%-100% word comprehension

80%+ word comprehension

70%+ word comprehension

60%+ word comprehension

< 60% word comprehension

Reference 1. CI Taskforce. Improving the standard of care for adults with hearing loss and the role of cochlear implantation: a systematic review of the evidence to develop clinical practice guidelines. Available at www.crd.york.ac.uk/REC=325393 Please seek advice from your health professional about treatments for hearing loss. Outcomes may vary, and your health professional will advise you about the factors which could affect your outcome. Always read the instructions for use.

19. Has the Hearing Stages Tool been useful to you when thinking about all the hearing management options possible before your hearing appointment?*

Not at all useful

Slightly useful

Moderately useful

Very useful

Extremely useful

20. Have you discussed your hearing stage, or the tool in general with anyone else before your hearing appointment?*

Yes

I will discuss my hearing stage

21. I have or I will discuss my hearing stage with the following (please tick all appropriate options)*

My partner

My parent

My brother or sister

My child/children

My friend/s

My GP

Other (please state)

Other

22. How easy was the Hearing Stages Tool to use?*

Extremely difficult

Somewhat difficult

Neither easy nor difficult

Somewhat easy

Extremely easy

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

Assistive Listening Devices

Hearables

Bone conduction/Middle ear implant

Combination of a hearing aid and a cochlear implant

Prescription hearing aid

Cochlear implant

24. Do you think the Hearing Stages Tool will change the way you discuss your hearing care plan with your audiologist at your hearing appointment?*

Definitely not

Probably not

Might or might not

Probably yes

Definitely yes

25. Do you have any comments you would like to make about the Hearing Stages Tool?

Range Slider

Phone

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

Hearing Stage Tool | Pre Appointment

Pre Appointment Questionnaire

What stage of hearing loss are you at?

Adults with hearing loss are not always aware of all the options that may be available to help optimise their hearing.

Consent Statement

About you

Your Hearing

Digital technology and the internet

Hearing Stages Tool

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