1. Are you still using your cochlear implant?	Yes	No	Sometimes
2. If so, how many hours per day on average?
3. Are you happy overall with the implant?	Yes	No	Somewhat
4. Is it better for you than hearing aid(s) were?	Yes	No	Somewhat
5. Does your spouse or family think it helps you?	Yes	No	Somewhat
6. Do you have any difficulties using the implant?	Yes	No	Sometimes
7. If so, what are they, or when do they occur (noisy situations, outside, etc.)?
8. Please list any complaints or concerns about the implant that you would like to have changed:
9. Would you recommend cochlear implants to others with hearing loss similar to yours?	Yes	No	Maybe
10. Is there anything else you would like your doctor or the audiologist to know?