Adult Hearing Health History
Patient’s Name:_________________________________Date:________________________
Occupation:_______________________________Date of Birth:_______________________
1.Have you been diagnosed with a hearing loss?YesNo
When:__________________________________________________________________
2.Are you tested your hearing last time?YesNo
Result?__________________________________________________________________
3.Are you having difficulty with your hearing?
Which ear/ears?RightLeftBoth
In what situation(s)?________________________________________________________
4.Do you have a family history of hearing loss?YesNo
Who:____________________________________________________________________
Do thay wear a hearing aid?YesNo
5.Do you have any tinnitus/ringing/noises in your ear(s?)YesNo
If yes,which ear?___________________________________________________________
6.Have you been exposed to loud noises, work or recreational,at any time in your life?
YesNo
Please explain:_____________________________________________________________
7.Have you had any surgery on your ears?YesNo
Please explain:_____________________________________________________________
8.Have you ever worn hearing aids before?YesNo
When?____________________________________________________________________
What type?________________________________________________________________
Please check any of the following you have exprienced:
________Ear infections________Diabetes________High Blood Pressure
________Head Injury________Kindney disease________Heart problems
________Head or neck surgery________Thyroid disease________Dizziness/Vertigo
____________Ototoxic Medications(i.e aminoglycosides/chemotherapy drugs)
List your Medications (or attach a list):______________________________________________
______________________________________________________________________________
What information would you like to gain from today’s visit?______________________________
______________________________________________________________________________
