Case History


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Adult Case History Name

1

Date

Do you feel that you are experiencing a hearing loss?

Yes

No

Yes

No

If yes, how long

2

Do you feel one ear is better than the other? If so, which ear

Right

Left

3

In what situations do you have difficulty hearing? (One on one conversation, groups, work, church, TV, etc.)

4

Have you worn a hearing aid?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If so, how long

5 Have you ever received medical treatment for significant ear problems? 6 Have you had recent ear pain or drainage? 7 Do you have any allergies? 8 Do you ever have noises in your ear? 9 Have you experienced dizziness in the past 90 days? 10 Have you ever experienced a serious head injury 11 Are you currently taking any medication? List

12 Have your ever had a serious illness which affected your hearing? 13 Have you ever been exposed to high noise levels? 14 Does anyone in your family have a hearing loss? If so what caused It?

15 Do you have any significant health problems or physical handicaps? 16 What questions or problems would you like help with today?