Pacific Hearing Service Adult History Form 1. What are

---

Pacific Hearing Service Adult History Form 1. What are your concerns regarding your hearing? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. How long have you had these concerns? _________________________________ 3. What are your most difficult listening situations? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. Do you have any history of medical problems with your ears? (For example, recurrent ear infections or history of ear surgery.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 5. Are you in good general health? If no, please explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 6. Daily medications: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 7. History of head trauma? ______________________________________________ 8. Headaches? _______________________________________________________ 9. Tinnitus? (Ringing in the ears) Please be specific. One or both ears? Consistent or intermittent? Does it keep you awake at night? __________________________________________________________________ __________________________________________________________________ 10. Dizziness? ________________________________________________________ 11. Is there any family history of hearing loss? _______________________________ 12. Have you ever worked in a noisy environment or had noisy hobbies? Please explain. __________________________________________________________________ __________________________________________________________________ 13. Do you have difficulty hearing on the phone? Yes No Which ear do you use on the phone? Right Left Both 14. Have you ever worn hearing aids before? If yes, please tell us about your experience.________________________________________________________ __________________________________________________________________