Hearing Health Profile

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Hearing Health Profile Age

DOB

Name How did you hear about us? When was tlre last time you had your hearing tested? Do you haver difficulty hearing?

E No E

Yes

How long hilve you noticed hearing loss?

E Recently (less than 90 days) D 1-3 years

E

Less

E

More than 3 years

than one year

In which of 1he following situations do you experience difficulty hearing or understanding?

E One-On-r)ne

Conversations

EICrowds

E

Phone

ls your hearing loss in one or

both ears?

E Spouse E In the Car E Restaurants E Right tr Left tr Both

tr

tr TV/Radio E Movies/Auditorium

tr

Church/SYnagogue

tr No tr Yes ears? E No E Yes Do you havre dnY ringing, buzztng, other noises in your ears? Do you have dizziness, loss of balance or light-headedness? tr No tr Yes

Do you havr: pain,discomfort or drainage from yours

E No

Have you ever been exposed to extremely loud noise? ls there anyone in your family

who has hearing

ElYes

trl No trYes

loss?

lf yes, please explain

Have you e'rer had surgery on your ear(s)? No

for? Do you take medication on a regular basis? lf yes, what are these medications

!

No

!

-

Ye:;

Do you have vision problems? Have you had surgery

tr No tr

Yes

Do you wear glasses?

with general anesthesia in the past 5 years?

Have you experienced any head injury or hezrd trauma?

device? device now?

Have you ever worn a hearing

D No tr

Yes

Do you we;nr hearing

E No tr

Yes

tr No tr Yes tr No tr Yes E No EYes

lf so, whatliype of hearing device do you wear? for that help? lf we find through our evaluation that we can help you, are you ready

Patient 5ignature

!

No E

Yes

Date

SmallGroups