{"id":1061,"date":"2016-12-21T18:58:27","date_gmt":"2016-12-21T18:58:27","guid":{"rendered":"https:\/\/legroupeforget.local\/?page_id=1061"},"modified":"2018-04-03T13:58:30","modified_gmt":"2018-04-03T17:58:30","slug":"hearing-screening-questionnaire","status":"publish","type":"page","link":"https:\/\/legroupeforget.stage.okam.io\/en\/test-your-hearing\/hearing-screening-questionnaire","title":{"rendered":"Hearing screening questionnaire"},"content":{"rendered":"<p>[vc_row][vc_column][vc_column_text]<\/p>\n<div class=\"row xxlarge padding-vertical-one padding-horizontal-half\">\n<div class=\"columns xsmall-12 medium-12 medium-centered large-12\">\n<h1 style=\"margin-top: 0;\"><span style=\"color: #0084b0;\">Hearing screening questionnaire<\/span><\/h1>\n<h2>Two minutes to answer the questionnaire<\/h2>\n<p>This hearing screening questionnaire will only take <span style=\"color: #0084b0;\"><strong>two minutes<\/strong><\/span> of your time. It assesses whether you need a comprehensive hearing test done by an audiologist.<\/p>\n<h2><span style=\"color: #0084b0;\">Obtain your results by answering the questionnaire<\/span><\/h2>\n<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&&(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&&t!=i[e].tag||null!=r&&r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_unknown gform_wrapper questionnaire_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_3' ><form method='post' enctype='multipart\/form-data'  id='gform_3' class='questionnaire gform_legacy_markup' action='\/en\/wp-json\/wp\/v2\/pages\/1061' >\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>16<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_3_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_1\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >1. When you speak to one person, do you ask him to repeat?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_1'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_1' type='radio' value='glikertcol17137a555'  id='choice_3_1_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_1' type='radio' value='glikertcol1b21d8c92'  id='choice_3_1_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_1' type='radio' value='glikertcol1a89c689d'  id='choice_3_1_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_3' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >2. Do you have any problems understanding when many people speak together?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_2'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_2' type='radio' value='glikertcol14b01068b'  id='choice_3_2_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_2' type='radio' value='glikertcol1b4dd9632'  id='choice_3_2_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_2' type='radio' value='glikertcol18a9da37c'  id='choice_3_2_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_38' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"1\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_38' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >3. Do you have any problems understanding when you don&#039;t see the face of the person who is speaking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_5'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_5' type='radio' value='glikertcol14b01068b'  id='choice_3_5_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_5' type='radio' value='glikertcol1b4dd9632'  id='choice_3_5_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_5' type='radio' value='glikertcol18a9da37c'  id='choice_3_5_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_39' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"2\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_39' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_7\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >4. Do you have any problems understanding when there is noise around you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_7'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_7' type='radio' value='glikertcol14b01068b'  id='choice_3_7_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_7' type='radio' value='glikertcol1b4dd9632'  id='choice_3_7_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_7' type='radio' value='glikertcol18a9da37c'  id='choice_3_7_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_40' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"3\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_40' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >5. Do you find that people mumble or do not speak loud enough (on T.V., friends, doctors)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_8'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_8' type='radio' value='glikertcol14b01068b'  id='choice_3_8_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_8' type='radio' value='glikertcol1b4dd9632'  id='choice_3_8_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_8' type='radio' value='glikertcol18a9da37c'  id='choice_3_8_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_41' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"4\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_41' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_12\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >6. Do you find that people speak too fast (on T.V., friends, doctors)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_12'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_12' type='radio' value='glikertcol14b01068b'  id='choice_3_12_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_12' type='radio' value='glikertcol1b4dd9632'  id='choice_3_12_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_12' type='radio' value='glikertcol18a9da37c'  id='choice_3_12_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_42' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"5\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_42' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"7\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"7\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_7' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_7' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_13\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >7. Do you have difficulty understanding on the phone?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_13'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_13' type='radio' value='glikertcol14b01068b'  id='choice_3_13_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_13' type='radio' value='glikertcol1b4dd9632'  id='choice_3_13_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_13' type='radio' value='glikertcol18a9da37c'  id='choice_3_13_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_43' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"6\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_43' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"8\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"8\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_8' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_8' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_16\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >8. Do you have any problems hearing the water running in the sink or bathtub when you are in another room?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_16'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_16' type='radio' value='glikertcol14b01068b'  id='choice_3_16_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_16' type='radio' value='glikertcol1b4dd9632'  id='choice_3_16_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_16' type='radio' value='glikertcol18a9da37c'  id='choice_3_16_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_44' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"7\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"7\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_44' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"9\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"9\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_9' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_9' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_18\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >9. Do you have any problems hearing the phone ringing when you are in another room or in the bathroom (at home or at other people&#039;s houses)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_18'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_18' type='radio' value='glikertcol14b01068b'  id='choice_3_18_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_18' type='radio' value='glikertcol1b4dd9632'  id='choice_3_18_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_18' type='radio' value='glikertcol18a9da37c'  id='choice_3_18_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_45' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"8\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"8\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_45' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"10\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"10\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_10' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_10' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_20\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >10. Do you have any problems hearing the doorbell at home or at other people&#039;s houses?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_20'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_20' type='radio' value='glikertcol14b01068b'  id='choice_3_20_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_20' type='radio' value='glikertcol1b4dd9632'  id='choice_3_20_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_20' type='radio' value='glikertcol18a9da37c'  id='choice_3_20_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_46' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"9\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"9\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_46' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"11\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"11\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_11' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_11' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_22\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >11. Do you have difficulty hearing when someone knocks on the door?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_22'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_22' type='radio' value='glikertcol14b01068b'  id='choice_3_22_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_22' type='radio' value='glikertcol1b4dd9632'  id='choice_3_22_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_22' type='radio' value='glikertcol18a9da37c'  id='choice_3_22_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_47' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"10\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"10\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_47' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"12\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"12\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_12' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_12' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_24\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >12. Have your family, friends, or neighbours made any comments about the volume of your radio or television being too loud?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_24'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_24' type='radio' value='glikertcol14b01068b'  id='choice_3_24_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_24' type='radio' value='glikertcol1b4dd9632'  id='choice_3_24_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_24' type='radio' value='glikertcol18a9da37c'  id='choice_3_24_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_48' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"11\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"11\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_48' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"13\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"13\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_13' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_13' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_29\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >13. Do you have a tendency to avoid other people because you are afraid of not understanding them?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_29'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_29' type='radio' value='glikertcol14b01068b'  id='choice_3_29_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_29' type='radio' value='glikertcol1b4dd9632'  id='choice_3_29_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29' type='radio' value='glikertcol18a9da37c'  id='choice_3_29_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_49' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"12\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"12\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_49' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"14\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"14\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_14' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_14' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_31\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >14. Do you prefer to avoid activities because of the noise around you (i.e., dining room, restaurant, family gathering, bingo)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_31'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Yes<\/th><th scope='col' class='gsurvey-likert-choice-label'>Sometimes<\/th><th scope='col' class='gsurvey-likert-choice-label'>No<\/th><\/tr><\/thead><tbody><tr><td data-label='Yes' class='gsurvey-likert-choice'><input name='input_31' type='radio' value='glikertcol14b01068b'  id='choice_3_31_1'   \/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_31' type='radio' value='glikertcol1b4dd9632'  id='choice_3_31_2'   \/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_31' type='radio' value='glikertcol18a9da37c'  id='choice_3_31_3'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_50' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"13\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"13\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_50' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"15\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"15\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_15' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_15' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_32\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\"><label class='gfield_label'  >15. How do you consider your hearing?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table class='gsurvey-likert' id='input_3_32'><thead><tr><th scope='col' class='gsurvey-likert-choice-label'>Good<\/th><th scope='col' class='gsurvey-likert-choice-label'>Slight hearing problem (occasional hearing problem)<\/th><th scope='col' class='gsurvey-likert-choice-label'>Moderate hearing problem (frequent hearing problem)<\/th><th scope='col' class='gsurvey-likert-choice-label'>Serious hearing problem (important hearing problems, nearly always)<\/th><\/tr><\/thead><tbody><tr><td data-label='Good' class='gsurvey-likert-choice'><input name='input_32' type='radio' value='glikertcol14b01068b'  id='choice_3_32_1'   \/><\/td><td data-label='Slight hearing problem (occasional hearing problem)' class='gsurvey-likert-choice'><input name='input_32' type='radio' value='glikertcol1b4dd9632'  id='choice_3_32_2'   \/><\/td><td data-label='Moderate hearing problem (frequent hearing problem)' class='gsurvey-likert-choice'><input name='input_32' type='radio' value='glikertcol18a9da37c'  id='choice_3_32_3'   \/><\/td><td data-label='Serious hearing problem (important hearing problems, nearly always)' class='gsurvey-likert-choice'><input name='input_32' type='radio' value='glikertcol32a4d8ee9d'  id='choice_3_32_4'   \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_33' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"14\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"14\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_3_33' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_3\").val(\"16\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_3\").val(\"16\");  jQuery(\"#gform_3\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_16' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_16' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_37\" class=\"gfield gfield_html gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Please fill out the following fields to obtain your results by email :<\/li><li id=\"field_3_55\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_55' >First name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_3_55' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_34\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_34' >Last name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_3_34' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_35\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_35' >City :<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_3_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_36\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_36' >Email :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_36' id='input_3_36' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_51\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_51' >Postal code :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_3_51' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_54' >Phone number :<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_3_54' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_52\" class=\"gfield no-label field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label screen-reader-text gfield_label_before_complex'  ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_52'><li class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='I agree to receive hearing health news 2 to 3 times a year.'  id='choice_3_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1'>I agree to receive hearing health news 2 to 3 times a year.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_53\" class=\"gfield spam-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><p>To make sure you receive your results by email, you may add the email address <a href=\"mailto:services@legroupeforget.com\">services@legroupeforget.com<\/a> to your contact list.<\/p><\/li><li id=\"field_3_56\" class=\"gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_3_56' >Phone<\/label><div class='ginput_container'><input name='input_56' id='input_3_56' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_3_56'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_3\"]){return false;}  window[\"gf_submitting_3\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} window[\"gf_submitting_3\"]=true;  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }' \/> <input type=\"submit\" id=\"gform_submit_button_3\" class=\"gform_button button\" value=\"Send\" onclick='if(window[\"gf_submitting_3\"]){return false;}  window[\"gf_submitting_3\"]=true;   createObject(3);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} window[\"gf_submitting_3\"]=true;  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }'> \n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsIjc3MWI2OTY0M2U0MTllMTg5YTNlYTA1MzUwYTYyODg3Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n<div style=\"font-size: 15px;\"><span style=\"color: #790000;\">*<\/span> Required field.<\/div>\n<h2><\/h2>\n<h2><\/h2>\n<h2 style=\"text-align: left;\"><span style=\"color: #0084b0;\">How the results of this hearing screening questionnaire are calculated?<\/span><\/h2>\n<h3><span style=\"color: #0084b0;\">For questions 1 to 14 inclusively:<\/span><\/h3>\n<ul>\n<li><span style=\"color: #969799;\">Every \u201cyes\u201d is worth 4 points,<\/span><\/li>\n<li><span style=\"color: #969799;\">each \u201csometimes\u201d is worth 2 points and<\/span><\/li>\n<li><span style=\"color: #969799;\">each \u201cno\u201d is worth 0 point.<\/span><\/li>\n<\/ul>\n<h3><\/h3>\n<h3><span style=\"color: #0084b0;\">For question 15:<\/span><\/h3>\n<ul>\n<li><span style=\"color: #969799;\">Each \u201ca\u201d is worth 0 point,<\/span><\/li>\n<li><span style=\"color: #969799;\">\u201cb\u201d 2 points,<\/span><\/li>\n<li><span style=\"color: #969799;\">\u201cc\u201d 3 points and<\/span><\/li>\n<li><span style=\"color: #969799;\">\u201cd\u201d 4 points.<\/span><\/li>\n<\/ul>\n<h3><span style=\"color: #0084b0;\">Your total<\/span><\/h3>\n<p>If the total is greater than 14, ask for a consultation with an audiologist, or with a healthcare professional for a referral in audiology.<\/p>\n<p><a title=\"Paying authorities\" href=\"\/en\/products\/paying-authorities\/\" target=\"_blank\" rel=\"noopener\">Learn more about the hearing aid accessibility program and its modalities<\/a>, or find the name of a physician, an E.N.T. specialist, an audiologist or an audioprosthetist in your neighbourhood, call now at 1-888-ENTENDRE or <a title=\"Make an appointment\" href=\"\/en\/make-an-appointment\/\" target=\"_blank\" rel=\"noopener\">make an appointment<\/a>.<\/p>\n<h3><span style=\"color: #0084b0;\">How was this hearing screening questionnaire conceived?<\/span><\/h3>\n<p>Reproduction needs special authorization from author, H\u00e9l\u00e8ne Caron, M.O.A. audiologist.<br \/>\nQuestionnaire realized by H\u00e9l\u00e8ne Caron, M.O.A., audiologist, <span style=\"color: #0084b0;\"><a href=\"https:\/\/www.ciusss-centresudmtl.gouv.qc.ca\/nos-installations\/centre-de-readaptation-en-deficience-physique-sensorielle-langage-auditive-et-motrice\/installation-raymond-dewar\/?L=%270\" target=\"_blank\" rel=\"noopener\">Institut Raymond-Dewar<\/a><\/span>, Scientific validation by Michel Picard, Ph.D., full professor of audiology, University of Montreal. Translated by Annie No\u00ebl, audiologist, with the collaboration of Dale Bonnycastle and Lilianne Brunetti, audiologists at the MacKay Rehabilitation Centre. Published in collaboration with the \u00abFondation Surdit\u00e9 et Communication of Institut Raymond-Dewar\u00bb.<\/p>\n<p style=\"text-align: left;\">\n<\/div>\n<\/div>\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text] Hearing screening questionnaire Two minutes to answer the questionnaire This hearing screening questionnaire will only take two minutes of your time. It assesses whether you need a comprehensive hearing test done by an audiologist. Obtain your results by answering the questionnaire * Required field. How the results of this hearing screening questionnaire are calculated? [&hellip;]<\/p>\n","protected":false},"author":55,"featured_media":0,"parent":3056,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Hearing screening questionnaire - Groupe Forget<\/title>\n<meta name=\"description\" content=\"Answer this hearing screening questionnaire and you will be able to find out if you need to have a complete hearing evaluation by an audiologist.\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Hearing screening questionnaire - Groupe Forget\" \/>\n<meta property=\"og:description\" content=\"Answer this hearing screening questionnaire and you will be able to find out if you need to have a complete hearing evaluation by an audiologist.\" \/>\n<meta property=\"og:url\" content=\"http:\/\/legroupeforget.stage.okam.io\/en\/test-your-hearing\/hearing-screening-questionnaire\" \/>\n<meta property=\"og:site_name\" content=\"Le Groupe Forget\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/cliniquesgroupeforget\" \/>\n<meta property=\"article:modified_time\" content=\"2018-04-03T17:58:30+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/legroupeforget.stage.okam.io\/wp-content\/uploads\/2018\/03\/logo_fr2x.png\" \/>\n\t<meta property=\"og:image:width\" content=\"262\" \/>\n\t<meta property=\"og:image:height\" content=\"110\" \/>\n<meta name=\"twitter:card\" content=\"summary\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebSite\",\"@id\":\"https:\/\/legroupeforget.stage.okam.io\/en\/#website\",\"url\":\"https:\/\/legroupeforget.stage.okam.io\/en\/\",\"name\":\"Le Groupe Forget\",\"description\":\"Le Groupe Forget\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/legroupeforget.stage.okam.io\/en\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"http:\/\/legroupeforget.stage.okam.io\/en\/test-your-hearing\/hearing-screening-questionnaire#webpage\",\"url\":\"http:\/\/legroupeforget.stage.okam.io\/en\/test-your-hearing\/hearing-screening-questionnaire\",\"name\":\"Hearing screening questionnaire - 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