Select Province

Gauteng

Western Cape

KwaZulu Natal

Free State

Eastern Cape

Mpumalanga

Limpopo

Northern Cape

North West

Who is this questionnaire for? *

Myself

A loved one

How long have your hearing concerns been noticeable? *

Suddenly (last few days)

Recently (last few months)

Around a year

More than a year

Not sure

How long have their hearing concerns been noticeable? *

Suddenly (last few days)

Recently (last few months)

More than a year

Not sure

Which of the following sound familiar to you? (Select any) *

Difficulty following conversations in noise

Asking others to repeat themselves

Turning the TV up louder than others prefer

Struggling in group conversations

Feeling tired after conversations

Ringing or buzzing sounds

Which of the following sound familiar to them? (Select any) *

Difficulty following conversations in noise

Asking others to repeat themselves

Turning the TV up louder than others prefer

Struggling in group conversations

Feeling tired after conversations

Ringing or buzzing sounds

Have these changes started affecting your daily life? *

Not really

Occasionally

More often than before

Yes, it’s becoming frustrating

Have these changes started affecting their daily life? *

Not really

Occasionally

More often than before

Yes, it's becoming frustrating for them

Has a professional hearing assessment been done in the past 2 years? *

Yes

No

Not sure

What is your preferred method of contact? *

Whatsapp

Phone call

Email

No preference

First Name *

Last Name *

Phone *

Email *

Postal Code *

I agree that HearFix may contact me regarding my questionnaire responses.

I would like to receive occasional educational updates about hearing health from HearFix. I understand I can unsubscribe at any time.

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