Confidential Patient History

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800 Falmouth Road Mashpee, MA 02649 Phone: (508) 539-9780 Fax: (508) 539-9780

714 Main Street (Rt. 6A) Yarmouth Port, MA 02675 Phone: (508) 385-5222 Fax: (508) 385-5224

Confidential Patient History - Date: ________________ Patient Name: ___________________________________

Birth Date: _________________________

Address: ________________________________________

Phone No.: _________________________

City: ___________________________ State: _______________ Zip: _________________

Email:____________________________________________ Please complete the following: MEDICAL HISTORY: Yes No Have you seen a doctor in the past six months? (Dr. _____________________) Yes No Have you seen a doctor specializing in diseases of the ear? If yes, give date ____________________ Reason ______________________ Yes No Have you ever had your hearing tested? If yes, give date ____________________ by whom ____________________ Yes No Have you ever had any type of ear surgery? If yes, type of surgery _____________________(Dr. ___________________) Yes No Do you take medicine every day? If yes, please list: _______________________________________________________________ ______________________________________________________________________________ Yes No Do you have any other medical conditions? If yes, please list: _______________________________________________________________ ABOUT YOUR EARS: Do you have any of these symptoms? Yes No Drainage from the ear Yes No Sudden or rapid hearing loss in the past 90 days Yes No Acute or chronic dizziness/vertigo Yes No Ringing or buzzing (tinnitus) in either ear Which ear? Right Left Both Right Left Yes No Which is your poorer ear? Same Yes No Have you ever seen a doctor for wax removal? Yes No Do you have a history of noise exposure (Industrial, Military, or Recreational) ABOUT YOUR HEARING: Do you experience difficulty with the following? Yes No Understanding conversation Yes No Hearing in a crowd Yes No Hearing on the telephone Which ear do you use on the phone? Right Left Either Yes No Hearing or understanding the television Yes No How long have you had a hearing problem? ____________________________ Yes No Does anyone else in your family have a hearing problem? What relationship? _____________________________________________ Yes No Do you now or have you ever worn a hearing aid? If yes, how do you think you may be helped? _______________________________________________ Yes No Are you ready for help if a hearing loss is discovered? Whom may we thank for referring you to us? ________________________________________________ Signature _____________________________________

Date ____________________