Adult Hearing History Form

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Affordable Headng, LLC

Adult Hearing History Today's

I

Date

D.o.B.-/--/-

Name

I Age

Sex: MaleD Female!

Address

zip.

State Email

Relationship

Accompanying Party Name Home

Teleohone: Work

Referred by

Current Occupation Health Insurance

Member Number

Company Name

Have you ever had a hearing test?

Yesn No!

Have you ever had Surgery on your ears?

Do you have a hearing problem?

Where

lf Yes, When

Yes! Non

lf Yes, Explain

Mild! Moderaten SevereD ls your hearing loss fluctuating? Yesn No!

YesD NoU

lf Yes, is

How long have you had the loss?

it:

Do you have a history of sudden or rapidly progressive hearing loss within the previous 90 days? lf you responded Yes to the above question, is your sudden hearing loss: Right Which ear do you have greater difficulty hearing?

Right! LeftD

Earn

Left

YesD

Earl

Both

NoD

Earsl

Unsuref-]

Do you have trouble hearing in any of the following situations? Men talking One on One talking Women talking Other (Please list)

YesD No! At social gatherings Yest-l No[J Background noise YesD Non Telephone Television

Yes!

Nol

Are you currently taking any prescription or nonprescription drugs?

Yeslf Yes! Yes!

YesD No!

Notr Non Notr For what...?

Please list

Present Symptoms / Do You have:

Yes! Notr lf Yes: RightD Left! Both! ls it: Constant! Periodicil Right! Leftl Bothtr Do you have ear pain, or discomfort? Yes! No!

NoisesiTinnitus in your ears?

Any history of, or active drainage from the ears within the previous 90 days? Do you have a history of ear infections? Do you currently have:

Yestr

NoD

NauseaD Headachesn

Have you fallen in the last year?

Yes! NoI

Yes!

Chronic Dizziness/VertigoD

List how many times and when

Notr

Affordable Hearing, LLC

Page 2

Adult Hearing History Primary Doctor's Name Doctor's Office Location Are you currently being treated by this Primary Dr., or another Dr. for ear problems of any kind?

YesD No!

lf yes, Explain May we have permission to contact your doctor(s)to send your Audiologic Records*:

Yes[

Non

lf Yes, Please Sign X (-lncludes Your Audiologic Report & Audiogram)

Have you ever been exposed to excessive noise levels without hearing protection:

Where?

Yes!

No!

Jobn Militaryn Recreationn (i.e., music! firearmsn motorcycles! aircraft!

power toolsn),

Other:

Do you have, or have you had:

lDiabetes

lHypoglycemia (low blood

Dlmbalance

lOther

trLow blood DKidney

pressure

disease

Dstroke

dizziness

DHistory of

lHlV

or

migraines

trHeart disease

Aids

Iserious head

nNo

High dose Vicodin:

Do you have any family member(s)with hearing

When did the family member(s) lose hearing?

uHigh fever

trauma

DFalling experiences

ls it satisfactory?

nYes !No

Quinine:

Who?

!Birth UMid-life tJLate-onsel lYes llNo

lf Yes?

nRight Dleft

Model

Make

trYes

!Yes trNo High dose Aspirin: nYes lNo

!Yes tlNo

loss? flYes lf No

Do you now, or have you ever worn a hearing aid? Year

Dvertigo (spinning)

flHigh blood pressure

To your knowledge, have you ever received lntravenous Antibiotics:

Chemotherapy: DYes

sugar)

trNo

lf Not, why?

Have you performed any research on hearing aids?

flYes INo

lf Yes, explain

(THrS SECTTON lS FOR OFFICE PERSONAL ONLY)

Visible congenital or traumatic deformity to the ear(s)?

nYes nNo

Audiometricair-bonegapequal to,orgreaterthan, 1SdBat500Hz, 1000Hz,and2000Hz? Comments/Observations

rUU

HCP

[Yes !No

nBoth