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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?