APD Screening Questionnaire

Use this screening tool to see if a consultation is right for you. If you have any questions before filling out the form, contact Urban Hearing here.

INSTRUCTIONS: The purpose of this scale is to identify problems your hearing loss may be causing you. Please select NO, SOMETIMES, or YES for each question. Do not skip a question if you avoid a situation because of your hearing problem. If you wear hearing instruments, please answer the way you hear without hearing devices.