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 without
- 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
