We believe that you achieve the best possible results with your hearing aids by consulting with an audiologist.  Read this news release from State Health officials urging consumers to the

  • potential risks of buying hearing aids withoutDecibel-Graphic
  • being evaluated by a licensed hearing healthcare professional


Name: ____________________________________ Today’s Date: ________________

DOB: _____/_____/_______ Gender: Male Female Primary Language: ____________

Current Employer: ____________________________ Occupation: _________________

Employment Status: Full-time Part-time Retired Unemployed Stay at home parent Student

Highest Level of Education:

Do you currently use tobacco? Yes No Amount per day: __________

Type: Cigarettes Cigars Pipe Smokeless tobacco

Do you currently drink alcoholic beverages? Yes No


How often? Daily Weekly Monthly Occasionally Rarely

Do you currently use recreational drugs? Yes No What: ___________________

How often? Daily Weekly Monthly Occasionally Rarely