Hearing Life

First Name*:

Last Name*:

Address*:

Suburb*:

State*:

Postcode*:

Phone*:

Email*:

Age*:

Gender*: Male Female

Current Employment*:

1 Which of the following would you miss the most if your hearing deteriorated?*: Enjoying Music
Conversations with friends or family
Sounds of Nature
Enjoying social occasions and parties

2 Do you suspect your hearing is not as good as it once was?*: Yes No Unsure

3 Where would you go first to discuss hearing loss?*: Your local doctor
An ear, nose and throat specialist (ENT)
An audiologist
Your local pharmacist
Friends or family members with the condition

4 Have you ever had your hearing tested?*: Yes No

5 Have any of the following ever suggested that you have a hearing test?*: Friends
A Family Member
Doctor
Work Colleague
Other

6 Do you have any family members who wear hearing aids?*: Yes No

7 Which of the following would you think are the most common contributing factors to hearing loss.: (Please number 1-5, where 1 is of the most concern, and 5 the least)

8 Tick if any of the following statements reflects your opinion about hearing aids?*: Hearing aids are noisy, whistle or don't work properly
Hearing aids are too big and obvious
Hearing aids are only for the elderly
The technology behind the latest hearing aids is amazing
Hearing aids can make a real difference to people's lives
Hearing aids make your hearing deteriorate faster

9 Have you ever experienced prolonged exposure to loud noise in a work environment?*: (Tick each answer where appropriate)
Not that comes to mind
Yes, working in a factory
Yes, in construction, mining, music or other noisy industry
Yes, Other

10 Would you consider wearing hearing aids if you were diagnosed with hearing loss?*: Yes No Maybe

11 Do you experience any of the following problems?*: Do you strain to follow conversations in noisy environments?
Do you often feel that people are mumbling rather than speaking clearly?
Do you often need to ask people to repeat what they've said?
Do you mishear words or sentences regularly?
Have telephone conversations become more difficult?
Persistent or intermittent ringing in your ears

12 Would you like a FREE hearing test (valued at $70) or a FREE trial of the largest digital hearing aids?*: Yes No

13 Do you read National Pharmacies "Vital Health" magazine?*: Always Sometimes Never Don't receive

14 Would you consider purchasing National Pharmacies "home brand" products?*: Yes No

15 Would you like to receive special offers, more savings and health information via National Pharmacies monthly e-newsletter?*: Yes No

16 Have you visited www.nationalpharmacies.com.au in the past 3 months?*: Yes No

17 Would you like to receive correspondence from HearingLife in the future?*: Yes No

David Hall National Pharmacies	Duncan Armour HEARINGLife

National Pharmacies Survey