Audiology Hearing Aid Fitting Follow-Up

Audiology Hearing Aid Fitting Follow-Up — Form Fields

This healthcare template includes 13 fields. Follow-up form for patients after hearing aid fitting to assess adjustment and satisfaction. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Date of Fitting (text, required)
• Hearing Aid Make and Model (text, required)
• Hearing Aid Type (dropdown selection, required) — options: Behind-the-Ear (BTE), Receiver-in-Canal (RIC), In-the-Ear (ITE), Completely-in-Canal (CIC), Invisible-in-Canal (IIC)
• Wearing Time Per Day (dropdown selection, required) — options: Under 2 Hours, 2-4 Hours, 4-8 Hours, 8-12 Hours, 12+ Hours
• Overall Satisfaction (rating, required)
• Sound Quality (rating, required)
• Comfort and Fit (rating, required)
• Listening Situations with Difficulty (checkboxes, optional) — options: Quiet Conversation, Noisy Restaurant, Phone Calls, Television, Outdoor, Group Meetings, Music
• Experiencing Feedback/Whistling (multiple choice, required) — options: Yes - Frequently, Yes - Occasionally, No
• Need Volume Adjustment (multiple choice, required) — options: Too Loud, Too Quiet, Just Right
• Specific Concerns or Adjustments Needed (long text, optional)