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Input Hearing Systems Patient’s Name: _____________________________________ Date: ____________________ Hearing Health History Medical History 1. Have you seen an ear specialist within the past 6 months? _______________________ 2. Physician’s name: ________________________________________________________ 3. Has your hearing in one ear worsened in the last 90 days (3 months)? _____________ 4. Which ear has more hearing loss? ___________________________________________ 5. Describe your primary concern with your hearing loss. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 6. Do you have now, or have you experienced in the past, any of the following? Dizziness Drainage Ear Deformity Ear Surgery – Type of surgery: __ _________________________ Date of surgery: ___________________________ Earwax accumulation/impaction Infection (in the ear canal or inside the ear) Pain Tinnitus (ringing, buzzing or other sounds in the ears) 7. Please list all medications you are currently taking, including over the counter medications, vitamins, herbs and any other supplements. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 8. Do you eat grapefruit or drink grapefruit juice? Yes No 9. Describe your lifestyle (work setting, hobbies, weekly activities, telephone use, TV, automobile): ____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5/23/2007 Patient’s Name: _____________________________________ Date: ____________________ Hearing Abilities Questionnaire 1. What is your hearing aid experience? I have a hearing aid and use it regularly on the ___ right ear, ___ left ear. I have a hearing aid but don’t use it or only use it occasionally. I have tried a hearing aid but returned it for credit. I have inquired about hearing aids at another office(s) but did not purchase at that time. I have never used a hearing aid. 2. Please rank the following three (3) factors in terms of their importance to you when purchasing a hearing aid. 1 = most important, 2 = moderately important, 3 = least important. Please use each number one time only. _____ Sound Quality and Clarity _____ Cost _____ Appearance 3. What motivated you to come in today? ______________________________________ _______________________________________________________________________ 4. Have you noticed people seem to mumble when speaking to you? _______________ 5. Do you often ask people to repeat what they have said? ________________________ 6. Do others complain that you set the TV volume too loud/high? __________________ 7. Do you sometimes hear words but have difficulty understanding them? ___________ 8. Please check the box below which corresponds to your ability to hear in the situations listed and check how often you are in that situation. Listening Situation Quiet Room (1 – 2 people) Television Music Restaurants Church Meetings/Lectures Work Place Telephone Conversations Car Meal Times (at home) Groups (4 – 6 people) City Street Large Social Gathering Radio Shopping 5/23/2007 How well do you hear in this situation? How often are you in this situation? Poor Fair Good Rarely Sometimes Often
