hearing health history

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Audiology Associates of East Texas David L. Twomey


1018 Pruitt Pl Tyler, TX 75703 Phone (903) 592-8374 Fax (903) 592-5293

Name:_______________________________________________ Date:______________ Primary Complaint/Symptom:_______________________________________________ Onset of Complaint/Symptom:_______________________________________________ For this section please mark all conditions that apply to you Left ear hearing impairment for: r none r < 3 years r 3-5 years r 5 or more years Right ear hearing impairment for: r none r < 3 years r 3-5 years r 5 or more years r have had an ear infection in the past r 1 year or r 5 years r it was treated by PCP/ENT r surgery: r right ear r left ear If so, the approx. dates: ______________________________ r myringotomy/ventilation tubes r tympanoplasty r mastoidectomy r stapedectomy r tinnitus (ringing): r left ear r ring/roar r crickets r occasional r constant r right ear r ring/roar r crickets r occasional r constant r family history of hearing impairment: r parents r siblings r grandparents/aunts/uncles r vertigo: If so, please describe:__________________________________________________________ r currently use a hearing aid: r right ear r left ear r both ears Social Information Living environment: r with spouse r alone r with adult children r child living w/parents r in a retirement community r in assistive living/nursing home Social activity: r attend church regularly r difficulty understanding preacher r play cards/dominoes r golf r dine out regularly r Sunday school r social clubs r interact with children/grandchildren regularly Telephone: preferred ear: r right rleft degree of difficulty on telephone:_____________________________________ primary use of telephone: r social r employment r infrequent Television: r no problem understanding r plays too loud for others r watch own TV r use closed captioning r do not watch TV regularly Occupational/recreational Loud Noise Exposure r no history of occupational noise exposure r military noise exposure: ________________________________________________________________ r type of occupational noise exposure______________________________________________________ Medical History How is your general health?_______________________________________________________________ List any conditions that you have now or have had in the past:___________________________________ ______________________________________________________________________________________ List any recent hospitalizations/surgeries:____________________________________________________ List any medications that you are taking:_____________________________________________________