YES NO YES NO YES NO YES NO YES NO NO YES NO

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ADULT CASE HISTORY FORM The following information is confidential.

Today’s Date: _____________________

Name: ________________________________________ DOB: ______________________ GENERAL Do you think you have a hearing problem

☐YES

☐ NO

If yes, how long have you noticed this problem? What do you feel is the cause of your hearing loss? Was the onset gradual or sudden? In which ear do you hear the best?

☐ Same in both ears

Have you ever been exposed to loud noises?

☐YES

☐Right

☐Left

☐NO

If yes, please describe: ________________________________________________________________ Does anyone in your family have hearing loss?

☐YES

☐NO

If so, who? ___________________________________________________________________________ Have you ever had your hearing tested?

☐YES

☐NO

If yes, when and what were the results? ________________________________________________________________________

MEDICAL Have you ever had earaches or drainage from your ears?

☐YES Have you ever had medical/surgical treatment for your ears? ☐YES Do you notice any buzzing, ringing or roaring in your ears? ☐YES If yes, which ear? ☐ Right ☐ Left

☐NO ☐NO ☐NO

Have you ever had any of the following: ☐ meningitis ☐scarlet fever ☐seizures ☐vision problems ☐ arthritis ☐ measles ☐ injury to head ☐ allergies ☐ depression/anxiety ☐hypertension ☐ mumps ☐ diabetes ☐ high fever ☐ pacemaker ☐communicable disease Please list any medications (including non-prescriptions) you are currently taking or have taken recently: ______________________________________________________________________________ ______________________________________________________________________________ HEARING HISTORY Do you have difficulty with any of the following: ☐Watching TV ☐ Using the telephone ☐ Meetings ☐ Restaurants ☐Worship service Do you have problems hearing any of the following: ☐Telephone ring ☐Doorbell or knocking ☐ Fire/smoke detector ☐ Sirens ☐ Alarm clock ☐ Baby cry ☐ Right

☐ Left

Have you ever worn a hearing aid?

☐ YES

☐NO

Do you use a hearing aid now?

☐ YES

☐NO

Which ear do you use on the telephone? HEARING AID HISTORY

If YES, how long have you had a hearing aid? ___________________________________________ On which ear do you use the hearing aid? ☐ Right Do you wear it regularly? Do you feel you benefit from it?

☐ YES ☐ YES

☐Left ☐NO ☐NO

☐Both ears

Please rank the following in order of importance (1-4), if a hearing aid is recommended for you: ____ Improved hearing in quiet ____ Improved hearing in noise ____ Cosmetic appearance ____ Expense