{"id":1061,"date":"2016-12-21T18:58:27","date_gmt":"2016-12-21T18:58:27","guid":{"rendered":"https:\/\/www.polycliniquedeloreille.com\/?page_id=1061"},"modified":"2017-02-09T15:05:12","modified_gmt":"2017-02-09T15:05:12","slug":"hearing-screening-questionnaire","status":"publish","type":"page","link":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire","title":{"rendered":"Hearing screening questionnaire"},"content":{"rendered":"<div class=\"row xxlarge padding-vertical-one padding-horizontal-half\">\n<div class=\"columns xsmall-12 medium-10 medium-centered large-8\">\n<h1><span style=\"color: #5d9c09;\">HEARING SCREENING QUESTIONNAIRE<\/span><\/h1>\n<h2><\/h2>\n<p>Answer this hearing screening questionnaire will take only a few minutes and you will be able to find out if you need to have a complete hearing evaluation by an audiologist.<\/p>\n<h2>Obtain your results by answering the questionnaire<\/h2>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework questionnaire_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><form method='post' enctype='multipart\/form-data'  id='gform_3' class='questionnaire' action='\/en\/wp-json\/wp\/v2\/pages\/1061' data-formid='3' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LewHDwqAAAAAI0DtbBWT95qR2525x-adzPdOZ8Y' data-tabindex='0'><input id=\"input_bfdac43ce5b88fb280a46e2b292cbf67\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_bfdac43ce5b88fb280a46e2b292cbf67\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero='1'>\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><span class='gf_step_page_name'><\/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 ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_60\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>Name<\/label><div class='ginput_container'><input name='input_60' id='input_3_60' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_60'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='1. When you speak to one person, do you ask him to repeat?' class='gsurvey-likert' id='input_3_1'><thead><tr><th id='likert_col_1_3_1' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_1' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_1' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_1'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_1' type='radio' value='glikertcol1b21d8c92'  id='choice_3_1_2'    aria-labelledby='likert_col_2_3_1'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_1' type='radio' value='glikertcol1a89c689d'  id='choice_3_1_3'    aria-labelledby='likert_col_3_3_1'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_3' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-3' 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 validation_below'><li id=\"field_3_2\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='2. Do you have any problems understanding when many people speak together?' class='gsurvey-likert' id='input_3_2'><thead><tr><th id='likert_col_1_3_2' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_2' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_2' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_2'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_2' type='radio' value='glikertcol1b4dd9632'  id='choice_3_2_2'    aria-labelledby='likert_col_2_3_2'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_2' type='radio' value='glikertcol18a9da37c'  id='choice_3_2_3'    aria-labelledby='likert_col_3_3_2'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_38' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_38' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-38' 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 validation_below'><li id=\"field_3_5\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='3. Do you have any problems understanding when you don&#039;t see the face of the person who is speaking?' class='gsurvey-likert' id='input_3_5'><thead><tr><th id='likert_col_1_3_5' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_5' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_5' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_5'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_5' type='radio' value='glikertcol1b4dd9632'  id='choice_3_5_2'    aria-labelledby='likert_col_2_3_5'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_5' type='radio' value='glikertcol18a9da37c'  id='choice_3_5_3'    aria-labelledby='likert_col_3_3_5'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-39' 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 validation_below'><li id=\"field_3_7\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='4. Do you have any problems understanding when there is noise around you?' class='gsurvey-likert' id='input_3_7'><thead><tr><th id='likert_col_1_3_7' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_7' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_7' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_7'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_7' type='radio' value='glikertcol1b4dd9632'  id='choice_3_7_2'    aria-labelledby='likert_col_2_3_7'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_7' type='radio' value='glikertcol18a9da37c'  id='choice_3_7_3'    aria-labelledby='likert_col_3_3_7'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_40' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_40' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-40' 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 validation_below'><li id=\"field_3_8\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='5. Do you find that people mumble or do not speak loud enough (on T.V., friends, doctors)?' class='gsurvey-likert' id='input_3_8'><thead><tr><th id='likert_col_1_3_8' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_8' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_8' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_8'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_8' type='radio' value='glikertcol1b4dd9632'  id='choice_3_8_2'    aria-labelledby='likert_col_2_3_8'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_8' type='radio' value='glikertcol18a9da37c'  id='choice_3_8_3'    aria-labelledby='likert_col_3_3_8'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_41' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-41' 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 validation_below'><li id=\"field_3_12\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='6. Do you find that people speak too fast (on T.V., friends, doctors)?' class='gsurvey-likert' id='input_3_12'><thead><tr><th id='likert_col_1_3_12' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_12' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_12' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_12'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_12' type='radio' value='glikertcol1b4dd9632'  id='choice_3_12_2'    aria-labelledby='likert_col_2_3_12'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_12' type='radio' value='glikertcol18a9da37c'  id='choice_3_12_3'    aria-labelledby='likert_col_3_3_12'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_42' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_7' class='gform_page' data-js='page-field-id-42' 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 validation_below'><li id=\"field_3_13\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='7. Do you have difficulty understanding on the phone?' class='gsurvey-likert' id='input_3_13'><thead><tr><th id='likert_col_1_3_13' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_13' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_13' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_13'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_13' type='radio' value='glikertcol1b4dd9632'  id='choice_3_13_2'    aria-labelledby='likert_col_2_3_13'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_13' type='radio' value='glikertcol18a9da37c'  id='choice_3_13_3'    aria-labelledby='likert_col_3_3_13'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_43' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_43' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_8' class='gform_page' data-js='page-field-id-43' 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 validation_below'><li id=\"field_3_16\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='8. Do you have any problems hearing the water running in the sink or bathtub when you are in another room?' class='gsurvey-likert' id='input_3_16'><thead><tr><th id='likert_col_1_3_16' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_16' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_16' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_16'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_16' type='radio' value='glikertcol1b4dd9632'  id='choice_3_16_2'    aria-labelledby='likert_col_2_3_16'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_16' type='radio' value='glikertcol18a9da37c'  id='choice_3_16_3'    aria-labelledby='likert_col_3_3_16'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_9' class='gform_page' data-js='page-field-id-44' 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 validation_below'><li id=\"field_3_18\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-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)?' class='gsurvey-likert' id='input_3_18'><thead><tr><th id='likert_col_1_3_18' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_18' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_18' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_18'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_18' type='radio' value='glikertcol1b4dd9632'  id='choice_3_18_2'    aria-labelledby='likert_col_2_3_18'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_18' type='radio' value='glikertcol18a9da37c'  id='choice_3_18_3'    aria-labelledby='likert_col_3_3_18'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_10' class='gform_page' data-js='page-field-id-45' 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 validation_below'><li id=\"field_3_20\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='10. Do you have any problems hearing the doorbell at home or at other people&#039;s houses?' class='gsurvey-likert' id='input_3_20'><thead><tr><th id='likert_col_1_3_20' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_20' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_20' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_20'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_20' type='radio' value='glikertcol1b4dd9632'  id='choice_3_20_2'    aria-labelledby='likert_col_2_3_20'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_20' type='radio' value='glikertcol18a9da37c'  id='choice_3_20_3'    aria-labelledby='likert_col_3_3_20'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_46' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_46' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_11' class='gform_page' data-js='page-field-id-46' 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 validation_below'><li id=\"field_3_22\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='11. Do you have difficulty hearing when someone knocks on the door?' class='gsurvey-likert' id='input_3_22'><thead><tr><th id='likert_col_1_3_22' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_22' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_22' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_22'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_22' type='radio' value='glikertcol1b4dd9632'  id='choice_3_22_2'    aria-labelledby='likert_col_2_3_22'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_22' type='radio' value='glikertcol18a9da37c'  id='choice_3_22_3'    aria-labelledby='likert_col_3_3_22'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_47' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_47' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_12' class='gform_page' data-js='page-field-id-47' 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 validation_below'><li id=\"field_3_24\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='12. Have your family, friends, or neighbours made any comments about the volume of your radio or television being too loud?' class='gsurvey-likert' id='input_3_24'><thead><tr><th id='likert_col_1_3_24' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_24' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_24' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_24'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_24' type='radio' value='glikertcol1b4dd9632'  id='choice_3_24_2'    aria-labelledby='likert_col_2_3_24'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_24' type='radio' value='glikertcol18a9da37c'  id='choice_3_24_3'    aria-labelledby='likert_col_3_3_24'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_48' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_13' class='gform_page' data-js='page-field-id-48' 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 validation_below'><li id=\"field_3_29\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='13. Do you have a tendency to avoid other people because you are afraid of not understanding them?' class='gsurvey-likert' id='input_3_29'><thead><tr><th id='likert_col_1_3_29' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_29' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_29' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_29'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_29' type='radio' value='glikertcol1b4dd9632'  id='choice_3_29_2'    aria-labelledby='likert_col_2_3_29'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_29' type='radio' value='glikertcol18a9da37c'  id='choice_3_29_3'    aria-labelledby='likert_col_3_3_29'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_49' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_49' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_14' class='gform_page' data-js='page-field-id-49' 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 validation_below'><li id=\"field_3_31\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='14. Do you prefer to avoid activities because of the noise around you (i.e., dining room, restaurant, family gathering, bingo)?' class='gsurvey-likert' id='input_3_31'><thead><tr><th id='likert_col_1_3_31' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Yes<\/th><th id='likert_col_2_3_31' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Sometimes<\/th><th id='likert_col_3_3_31' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_31'\/><\/td><td data-label='Sometimes' class='gsurvey-likert-choice'><input name='input_31' type='radio' value='glikertcol1b4dd9632'  id='choice_3_31_2'    aria-labelledby='likert_col_2_3_31'\/><\/td><td data-label='No' class='gsurvey-likert-choice'><input name='input_31' type='radio' value='glikertcol18a9da37c'  id='choice_3_31_3'    aria-labelledby='likert_col_3_3_31'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_50' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_15' class='gform_page' data-js='page-field-id-50' 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 validation_below'><li id=\"field_3_32\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-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 aria-label='15. How do you consider your hearing?' class='gsurvey-likert' id='input_3_32'><thead><tr><th id='likert_col_1_3_32' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Good<\/th><th id='likert_col_2_3_32' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Slight hearing problem (occasional hearing problem)<\/th><th id='likert_col_3_3_32' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Moderate hearing problem (frequent hearing problem)<\/th><th id='likert_col_4_3_32' scope='col' role='presentation' 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'    aria-labelledby='likert_col_1_3_32'\/><\/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'    aria-labelledby='likert_col_2_3_32'\/><\/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'    aria-labelledby='likert_col_3_3_32'\/><\/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'    aria-labelledby='likert_col_4_3_32'\/><\/td><\/tr><\/tbody><\/table><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_33' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_3_33' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_16' class='gform_page' data-js='page-field-id-33' 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 validation_below'><li id=\"field_3_37\" class=\"gfield gfield--type-html gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please fill out the following fields to obtain your results by email :<\/li><li id=\"field_3_56\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'>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_56' id='input_3_56' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_34\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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_36\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_51\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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_35\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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_55\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_55'><li class='gchoice gchoice_3_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='I agree to receive hearing health news 2 to 3 times a year.'  id='choice_3_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>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 gfield--type-html spam-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>To make sure you receive your results by email, you may add the email address <a href=\"mailto:services@polycliniquedeloreille.com\">services@polycliniquedeloreille.com<\/a> to your contact list.<\/p><\/li><li id=\"field_3_57\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='Y' \/><\/div><\/li><li id=\"field_3_58\" class=\"gfield gfield--type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='N' \/><\/div><\/li><li id=\"field_3_59\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h6><span style=\"color: #474747;\"><em>By clicking \u201c<strong>Send<\/strong>,\u201d you consent to sharing your personal information with Polyclinique de l\u2019Oreille and to being contacted by Polyclinique de l\u2019Oreille to answer your questions, all in accordance with the <\/em><a href=\"https:\/\/www.polycliniquedeloreille.com\/en\/privacy-policy\"><span style=\"color: #ff6600;\"><em>Security and Privacy Policy<\/em><em>.<\/em><\/span><\/a><\/span><\/h6><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type=\"submit\" id=\"gform_submit_button_3\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this); createObject(3);\" data-submission-type=\"submit\" value=\"Send\"> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\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_currency' data-currency='CAD' value='GOq\/g1r9P6mc6e045QNyyMcxSaOnM8fbLOnabwH59LXyUwtir0BiGANgw7mNH\/4cUMzDdC1RmeA7eepGlhyVkjN1a8PweRshEupVkRmtdXRslpw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsIjA4MDBmYTg4ZWU4YjEyYTM4YTA3N2RiMjljNGEyMTliIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='2' \/>\n            <input type='hidden' autocomplete='off' 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><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/www.polycliniquedeloreille.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/www.polycliniquedeloreille.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_3\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 3, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<div style=\"font-size: 15px;\"><span style=\"color: #790000;\">*<\/span> All questions are required.<\/div>\n<h2><\/h2>\n<h2><\/h2>\n<h2 style=\"text-align: left;\">How the results of this hearing screening questionnaire are calculated?<\/h2>\n<h3>For questions 1 to 14 inclusively:<\/h3>\n<ul>\n<li>Every \u201cyes\u201d is worth 4 points,<\/li>\n<li>each \u201csometimes\u201d is worth 2 points and<\/li>\n<li>each \u201cno\u201d is worth 0 point.<\/li>\n<\/ul>\n<h3><\/h3>\n<h3>For question 15:<\/h3>\n<ul>\n<li>Each \u201ca\u201d is worth 0 point,<\/li>\n<li>\u201cb\u201d 2 points,<\/li>\n<li>\u201cc\u201d 3 points and<\/li>\n<li>\u201cd\u201d 4 points.<\/li>\n<\/ul>\n<h3>Your total<\/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\">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\">make an appointment<\/a>.<\/p>\n<h3>How was this hearing screening questionnaire conceived?<\/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, <a style=\"color: #5d9c09;\" 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\">Institut Raymond-Dewar<\/a>, 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","protected":false},"excerpt":{"rendered":"<p>HEARING SCREENING QUESTIONNAIRE Answer this hearing screening questionnaire will take only a few minutes and you will be able to find out if you need to have a complete hearing evaluation by an audiologist. Obtain your results by answering the questionnaire * All questions are required. How the results of this hearing screening questionnaire are [&hellip;]<\/p>\n","protected":false},"author":53,"featured_media":0,"parent":1305,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1061","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Hearing screening questionnaire - Polyclinique de l&#039;Oreille<\/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=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Hearing screening questionnaire - Polyclinique de l&#039;Oreille\" \/>\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=\"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire\" \/>\n<meta property=\"og:site_name\" content=\"Polyclinique de l&#039;Oreille\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/polycliniquedeloreille\/\" \/>\n<meta property=\"article:modified_time\" content=\"2017-02-09T15:05:12+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\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\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\\\/hearing-screening-questionnaire\",\"url\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\\\/hearing-screening-questionnaire\",\"name\":\"Hearing screening questionnaire - Polyclinique de l&#039;Oreille\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#website\"},\"datePublished\":\"2016-12-21T18:58:27+00:00\",\"dateModified\":\"2017-02-09T15:05:12+00:00\",\"description\":\"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.\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\\\/hearing-screening-questionnaire#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\\\/hearing-screening-questionnaire\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\\\/hearing-screening-questionnaire#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Complete hearing test\",\"item\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/en\\\/complete-hearing-test\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Hearing screening questionnaire\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#website\",\"url\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/\",\"name\":\"Polyclinique de l'Oreille\",\"description\":\"La Polyclinique de l&#039;Oreille\",\"publisher\":{\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#organization\",\"name\":\"Polyclinique de l'Oreille\",\"url\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/wp-content\\\/uploads\\\/2021\\\/02\\\/polyclinique_logo2x.jpg\",\"contentUrl\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/wp-content\\\/uploads\\\/2021\\\/02\\\/polyclinique_logo2x.jpg\",\"width\":402,\"height\":84,\"caption\":\"Polyclinique de l'Oreille\"},\"image\":{\"@id\":\"https:\\\/\\\/www.polycliniquedeloreille.com\\\/#\\\/schema\\\/logo\\\/image\\\/\"},\"sameAs\":[\"https:\\\/\\\/www.facebook.com\\\/polycliniquedeloreille\\\/\"]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Hearing screening questionnaire - Polyclinique de l&#039;Oreille","description":"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.","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire","og_locale":"en_US","og_type":"article","og_title":"Hearing screening questionnaire - Polyclinique de l&#039;Oreille","og_description":"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.","og_url":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire","og_site_name":"Polyclinique de l&#039;Oreille","article_publisher":"https:\/\/www.facebook.com\/polycliniquedeloreille\/","article_modified_time":"2017-02-09T15:05:12+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire","url":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire","name":"Hearing screening questionnaire - Polyclinique de l&#039;Oreille","isPartOf":{"@id":"https:\/\/www.polycliniquedeloreille.com\/#website"},"datePublished":"2016-12-21T18:58:27+00:00","dateModified":"2017-02-09T15:05:12+00:00","description":"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.","breadcrumb":{"@id":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test\/hearing-screening-questionnaire#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/www.polycliniquedeloreille.com\/en"},{"@type":"ListItem","position":2,"name":"Complete hearing test","item":"https:\/\/www.polycliniquedeloreille.com\/en\/complete-hearing-test"},{"@type":"ListItem","position":3,"name":"Hearing screening questionnaire"}]},{"@type":"WebSite","@id":"https:\/\/www.polycliniquedeloreille.com\/#website","url":"https:\/\/www.polycliniquedeloreille.com\/","name":"Polyclinique de l'Oreille","description":"La Polyclinique de l&#039;Oreille","publisher":{"@id":"https:\/\/www.polycliniquedeloreille.com\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/www.polycliniquedeloreille.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/www.polycliniquedeloreille.com\/#organization","name":"Polyclinique de l'Oreille","url":"https:\/\/www.polycliniquedeloreille.com\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/www.polycliniquedeloreille.com\/#\/schema\/logo\/image\/","url":"https:\/\/www.polycliniquedeloreille.com\/wp-content\/uploads\/2021\/02\/polyclinique_logo2x.jpg","contentUrl":"https:\/\/www.polycliniquedeloreille.com\/wp-content\/uploads\/2021\/02\/polyclinique_logo2x.jpg","width":402,"height":84,"caption":"Polyclinique de l'Oreille"},"image":{"@id":"https:\/\/www.polycliniquedeloreille.com\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/polycliniquedeloreille\/"]}]}},"_links":{"self":[{"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/pages\/1061","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/users\/53"}],"replies":[{"embeddable":true,"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/comments?post=1061"}],"version-history":[{"count":17,"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/pages\/1061\/revisions"}],"predecessor-version":[{"id":2162,"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/pages\/1061\/revisions\/2162"}],"up":[{"embeddable":true,"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/pages\/1305"}],"wp:attachment":[{"href":"https:\/\/www.polycliniquedeloreille.com\/en\/wp-json\/wp\/v2\/media?parent=1061"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}