SoundBite Hearing System Long Term Multi Site Patient Use Study Questionnaire CLN0006

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Subject ID Number: ________________ Date completing this survey: ____________

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SoundBite Hearing System Long Term Multi Site Patient Use Study Questionnaire

CLN0006

(Select one)

SSD CHL

(Select one) 6 Month Follow-up 12 Month Follow-up

1. Overall, how satisfied were you with the performance of your device in terms of addressing your hearing problem (circle one)?

a. Very Satisfied b. Satisfied

c. Slightly Satisfied d. Slightly Dissatisfied e. Dissatisfied

f. Very Dissatisfied

2. How satisfied were you with the quality of sound delivered by the device? (circle one) a. Very Satisfied

b. Satisfied

3. Please use the scale below to rate the performance of your device in terms of how well it improved your experience in each of the following situations (write a letter on each line from 3.1 to 3.8):

a. Very much improved b. Improved

c. Slightly improved d. No change e. Worse

____ 3.1 Hearing in noisy environments

____ 3.2 Hearing a person speaking to you on your deaf side (SSD only) ____ 3.3 Your ability to tell where sounds are coming from

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____ 3.4 Your ability to tell how close or far away a sound is ____ 3.5 Your ability to participate in group conversations ____ 3.6 Your experience of listening to music, TV, or radio ____ 3.7 Your overall confidence in group situations

____ 3.8 Your overall quality of life

4. Compared to your previous situation in which you had no device and your hearing problem was left untreated, do you prefer having this hearing device?

a. Very Much Prefer having the device b. Prefer having the device

c. Slightly Prefer having the device

d. Slightly Prefer my previous situation of not having the device e. Prefer my previous situation of not having the device

f. Very Much Prefer my previous situation of not having the device

5. How satisfied were you with the experience of wearing the device?

6. How long did it take you to become acclimated to wearing your device?

a. Right away b. Within 24 hours c. Within 2-4 days d. About a week e. More than a week

f. Have just become acclimated

7. How satisfied were you with your ability to speak while wearing the device once you had acclimated to it?

8. How satisfied were you with your ability to eat while wearing the device?

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9. How satisfied were you with the process of getting your device in terms of convenience?

10. How likely are you to recommend this device to a friend who had the same hearing problem as yours?

a. Very likely b. Likely

c. Slightly Likely d. Unlikely e. Very Unlikely

11. Please complete the following sentence, using the answer choices listed below , to accurately describe your experience. The SoundBite Hearing System_________my expectations.

a. Met my expectations

b. Somewhat met my expectation

c. Somewhat did not meet my expectations d. Did not meet my expectations

e. By far did not meet my expectations

12. What do you like most about the SoundBite system? What do you like least?

Most

Least

13. Is there any specific part of the SoundBite system you feel should be changed or improved?

a. Yes b. No

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14. If you answered “yes” to question #12, please fill out the section below.

If there was ONLY one part you feel should be changed what would it be?

What other changes or improvements would you recommend, if any?

15. Do you feel the SoundBite system was a good value for the money? (please circle one) a. Yes

b. No c. Not sure

16. If you answered “No” to question #14. Why?

17. Please provide any other comments or suggestions, you would like to share regarding your experience with the SoundBite Hearing System.