patient history

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PATIENT HISTORY ^^LAudio Your Name:

Date:

Medical & Hearing History Is this your first hearing test?

YES NO

Why do you want to have your hearing tested today?

Have you ever had ear surgery?

I w a n t to be sure it's normal.

Do you have a history of ear infections?

My family suggested t h a t I do this,

Do you have a family history of hearing loss?

I feel my hearing is poor.

Have you ever worked around any noise?

I think I need hearing aids.

Have you had head trauma?

My employer has required it.

Currently experiencing dizziness or lightheadedness? If so, what direction do you spin? If so, do you spin, or does the room spin? Do you notice ringing/noise in your ears?

Please list situations in which you would like to hear and/or understand better:

If so, does it keep you awake at night? If so, does it bother you during the day? If so, is it worse in one ear? Which one? Do you think you have hearing loss? If so, which ear, or both? If so, how long have you noticed this? Less than 1 year

2-5 years

More than 5 years

Do you have difficulty understanding in a group? Do you have difficulty understanding TV or radio?

If we were to find out through this evaluation that you could be helped by hearing instruments, are you ready for that help?

Do you feel frustrated trying to listen? Do you avoid going places?

YES

MAYBE

NO

Do you ask for people to repeat? Do you have difficulty listening to worship services? Do you have difficulty listening in a restaurant?

Have you worn hearing instruments before?

Which is the MOST important to you?

_ Cost Hearing in Noisy Environments . Cosmetics / Size of hearing aid

If so, how long did you wear them? If so, were you satisfied with them? If so, in which ear did you wear them?

Cost

Which is secondary?

Hearing in Noisy Environments Cosmetics / Size of hearing aid

Notes:

Which is the LEAST important?

_ Cost _ Hearing in Noisy Environments . Cosmetics / Size of hearing aid