Download Adult Case History

The Listening Center at Johns Hopkins
601 N. Caroline Street, Suite 6009
Baltimore, Maryland 21287
410-955-9397
410-614-9167(fax)
Adult Case History
I. GENERAL INFORMATION:
Name:
_________________________________________________________________________
Address:
_________________________________________________________________________
Phone:
_________________________________________________________________________
Birth date:
_________________________________________________________________________
E-Mail:
_________________________________________________________________________
Occupation and Employer: _____________________________________________________________
Marital Status:
S
M
W
D
Name of Spouse or significant other: _____________________________________________________
E-mail Address and phone# of significant other:____________________________________________
II. HEARING and COMMUNICATION HISTORY
1. When was your hearing loss first diagnosed? (RIGHT) _______ (LEFT) __________
2. Which do you feel is your better hearing ear?
Left
Right
Same
3. What is the cause of your hearing loss? _________________________________________________
4. Please circle which best describes your hearing loss: Sudden Progressive Stable Since birth
5. Is there a family history of hearing loss? Yes
No
6. Do you have tinnitus (noises in your ear)? R: Yes
No
Who? ______________________________
L: Yes No
If, yes please describe ______________________________________________________________
7. Do you have dizziness? Yes
No Sometimes
If yes, please describe and indicate how often the episodes occur?
___________________________________________________________________________
8. How do you prefer to communicate?
ASL
Signed English Lip-reading
Cued Speech
Oral
Other ____________________________________________________________________________
Do you need an interpreter?
□ Yes □ No
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II. Hearing Aid History: (please complete)
1. Do you wear hearing aids?
Yes
a. If yes, which ear?
No
Left
Right
Both
2. What year did you first start wearing hearing aids? Left ________ Right _________
3. When and where did you get your current hearing aids?
a.
Left______________________________________________________________
b. Right _____________________________________________________________
III. Health History:
1. Do you currently take any medications? Yes
No
If Yes, please list (or attach list): _________________________________________
___________________________________________________________________________
Do you currently have any health concerns or problems?
If yes, please list: _____________________________________________________
__________________________________________________________________________
Please list any health problems or concerns.
Any complications at birth? Yes No
IF yes, explain: _______________________________________________________
Any vision problems? Yes No
IF Yes, explain:_______________________________________________________
RELATED INFORMATION
1). Have you ever met or know someone with a cochlear implant? Yes No
If yes, who?___________________________________________________________________
2). Who referred you or how did you learn of a cochlear implant? _______________________________
3). How do you feel the cochlear implant could benefit you?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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