Hearing Health Enquiry Form

Take a minute to answer these simple questions and let us help you take the first step towards better hearing.

Basic Information

Full Name

Age Group
Below 1818-3031-5051-6565+

Contact Number

Email Address

Hearing Experience
Do you feel difficulty in hearing in the following situations? (Select all that apply)
While talking on the phoneIn group conversationsWhile watching TV / listening to musicIn noisy places (restaurants, traffic, gatherings)One-on-one conversations

Have your family/friends noticed that you:
Turn the TV/radio volume too highFrequently ask them to repeatRespond inappropriately sometimes

Do you experience any of these?
Ringing / buzzing sounds in the ear (Tinnitus)Ear fullness or pressureSudden or gradual hearing loss

Medical / Lifestyle Information
Have you ever had:
Ear infectionsEar surgeryHead injuryLong-term exposure to loud sounds (factory, music, traffic, headphones)

Do you currently use a hearing aid?
YesNo

If yes, specify brand/model (optional)

Your Interest / Enquiry
What are you interested in? (Select all that apply)
Free hearing check-upComprehensive diagnostic testHearing aid trialTinnitus counselling/managementPaediatric hearing evaluationCochlear implant consultationSpeech therapy services

Preferred Appointment Mode
In-clinic visitOnline consultationHome visit (if available)

Best Time to Contact You
MorningAfternoonEvening

Final Step
I would like to receive updates and tips on hearing health
YesNo