Download adult case history - Audio Hearing Center

ADULT CASE HISTORY
Patient: _________________________________ Age: _______ Date: ______________________________
What is the primary purpose for this appointment? ______________________________________________
HEARING HISTORY
Yes / No 1. Do you think you have a hearing loss? (If no skip to question #2)
A. Which ear do you hear better from? Right / Left / Both (same)
B. When did you first notice your hearing loss? _____________________________________________
C. Did this occur suddenly or gradually? ___________________________________________________
D. What do you think caused your hearing loss? _____________________________________________
E. Does your hearing fluctuate? Yes / No
If yes how often and when? ________________________________________________________
F. Does anyone in your family have a hearing loss? Yes / No
Who? _______________ What was the cause? _________________________________________
G. Did you have a permanent hearing change after a childhood illness? Yes / No
Yes / No 2. Have you ever had a hearing test or screening before? (If no skip to question #3)
A.Where and when was your last hearing test completed? _____________________________________
Was a hearing loss present? Yes / No Comments _____________________________________________
Were hearing aids recommended? Yes / No Comments ________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
/
/
/
/
/
/
/
/
/
/
No
No
No
No
No
No
No
No
No
No
3. Do you have difficulty understanding speech in a group of people?
4. Do you often ask that statements, questions and directions be repeated?
5. Do you hear people speaking, but have difficulty understanding words?
6. Must others ever raise their voices or move closer to help you hear them?
7. Do you have to turn the television up louder than normal to hear clearly?
8. Do you ever have to concentrate so much to listen that you tire from it?
9. Have you ever avoided a situation because of your hearing problem?
10. Do you have difficulty understanding conversations in the car?
11. Do you have difficulty understanding on the phone?
12. Do you hear some people better than others?
If yes, describe: _________________________________________________________
/ No 13. Have you tried or worn hearing aids?
How long? ____________________ Which ear? right / left / both
Manufacturer and Model _________________ Style ___________________________
Any problems with the aid(s)? _____________________________________________
/ No
14. Have you had or do you currently have non-medically managed diabetes?
/ No
15. Have you had chemotherapy within the last 6 months?
/ No
16. Have you had or do you currently have a compromised immune system?
/ No
17. Have you taken or do you currently take prescription blood thinners?
TINNITUS
Yes / No 18. Do you have constant or intermittent ringing, buzzing or noises in your ears?
(If no skip to question #19)
A. Which ear?
Right / Left / Both
B. Which ear is worse?
Right / Left / Both (same)
C. How long have you had these head noises? ____________ months / years
(continued)
D. Have these head noises recently changed? Yes / No
E. Have you consulted a professional regarding the tinnitus? Yes / No
Comments: __________________________________________________________________
F. Does background noise block out the noise in your ears? Yes / No
G. Do you use any of the following? Check all that apply
_____ salt/sodium _____ caffeine/coffee ____ aspirin ____ cigarettes ____ alcohol
(Adult Case History continued on back)
DIZZINESS
Yes / No 19. Do you experience dizziness or lightheadedness? (If no skip to question #20)
A. Describe this: _____________________________________________________________________
B. When did the dizziness or lightheadedness begin? ___________________________months/years
C. How frequently do the episodes occur? _________________________________________________
D. Do you experience the following?
_____room spinning _____you spinning _____nausea _____lightheadedness
E. Have you consulted a professional regarding this? Yes / No
Comments: ___________________________________________________________________
NOISE EXPOSURE HISTORY
Yes / No 20. Have you ever been exposed to excessive noise? (If no skip to question #21)
A. Please indicate the following:
Length of
Are you currently
Did you use
Exposure
exposed to these
hearing protection
Military Service
________
Yes / No
Yes / No
Factory/construction work/farming ________
Yes / No
Yes / No
Loud motors
________
Yes / No
Yes / No
Home power tools
________
Yes / No
Yes / No
Hunting/recreational shooting
________
Yes / No
Yes / No
Other: _________________________________________________________________
B. What kind of hearing protection have you used? _________________________________________
C. Have you ever been near an explosion? Yes / No Describe: ______________________________
MEDICAL HISTORY
Yes / No 21. Do you have a history of ear problems? (Please check all that are appropriate)
____ ear infections
____ ear-canal discharge
____ soreness/pain in the ears
____ excessive wax
____ tubes in the eardrum
____ hole/perforated eardrum
other ____________________________________________________________________
Yes / No 22. Have you ever had ear surgery? Describe: ____________________________________
Yes / No 23. Do you have any other medical problems? Check all that apply
____ heart disease ____ diabetes ____ high blood pressure ____ stroke ____ asthma
____ meningitis
____ mumps ____ scarlet fever Other:________________________
surgeries: _________________________________________________________________
Yes / No 24. Do you have frequent or severe headaches? How often? _________________________
Yes / No 25. Have you had a fever over 104 degrees? When?___________ For how long? __________
Yes / No 26. Have you ever had a head injury? (If no skip to question #27)
A. Were you unconscious? Yes / No B. Did you have any loss of hearing? Yes / No
Yes / No 27. Do you take any medications daily? If so, what? _________________________________
Yes / No 28. Do you have any allergies? Describe: __________________________________________
Yes / No 29. Do you have numbness in your face?
Yes / No 30. Do you have a pacemaker or implanted defibrillator? Describe: _____________________
ADDITIONAL INFORMATION
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Revised 1/5/2012