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Do you wear a cochlear implant?
 
Yes
 
No
 
 
 
Do you know somebody that wears a cochlear implant?
 
Yes
 
No
 
 
 
Do you think the cochlear implant has affected your life?
 
Strongly Agree
 
Agree
 
Neutral
 
Disagree
 
Strongly Disagree
 
 
 
List reasons why you, or a person you know would or would not recommend a cochlear implant.
   
 
 
 
Has a cochlear implant made a positive impact on a persons’ life you know?
 
Strongly Agree
 
Agree
 
Neutral
 
Disagree
 
Strongly Disagree
 
 
 
Have you had a negative experience with a cochlear implant?
 
Yes
 
No
 
 
 
Would you recommend a cochlear implant?
 
Absolutely Yes
 
Yes
 
No
 
 
 
Did the cochlear implant cause any emotional complications for you?
 
Yes
 
Somewhat
 
No
 
 
 
Has the cochlear implant caused any emotional complications for someone you know?
 
Yes
 
Somewhat
 
No
 
 
 
Did the topic of receiving a cochlear implant cause dispute between you and a loved one?
 
Absolutely Yes
 
Yes
 
No
 
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