Download Supplemental Adult Hearing Case History Form

UNIVERSITY OF HAWAI'I SPEECH AND HEARING CLINIC
ADULT CASE HISTORY FORM
HEARING PROBLEMS
Please answer the following questions as best you can. If you cannot answer some of the questions, leave
them blank. Your answers will help in understanding your child’s problem and save time during the
conference. (An EO/AA Institution)
RETURN TO: University of Hawai'i Speech and Hearing Clinic
677 Ala Moana Blvd., Suite #625
Honolulu, Hawai'i 96813.
A. Hearing and Related Symptoms
Date: _____________________________
Please check all that apply to your current symptoms.
□
Hearing loss, which ear? _____________
□
Distracted by background noise
□
Ear drainage, which ear? _____________
□
Oral and written expression problems
□
Ear pain/discomfort, which ear? _______
□
Difficulty remembering what you hear
□
Fullness/pressure, which ear? _________
□
Difficulty reading
□
Dizziness or vertigo
□
Difficulty using telephone
□
Tinnitus (ringing, noise), which ear? ____
□
Difficulty listening to the TV
□
Fluctuating hearing loss, which ear? ____
□
Sensitivity to loud sounds
□
Problems following directions
□
Other ___________________________
If you have a hearing difficulty, which ear is your better hearing ear?
□ Right □ Left □ Equal
When did your hearing problem(s) first developed? ____________________________________
What is known or suspected cause of your hearing difficulty? ____________________________
Has your hearing been tested before?
□
No
□
Yes, when was the last hearing test? __________________ Where?___________________
Results: ______________________________________________________________
How does your hearing difficulty affect your daily life?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Rev. 8/6/13
Have you ever worn any of the following devices?
□ No □ Yes, □Right/ □Left / □ Both Ears
□ Hearing aid
Make/Model:___________________________________________
□ Cochlear implant
Make/Model: ___________________________________________
□ BAHA
Make/Model: ___________________________________________
□ FM system
Make/Model: __________________________________________
□ Other _____________
Make/Model: ___________________________________________
If yes, where and when did you obtain them? Were you satisfied?
□ No
□ Yes
Where ____________________________________________________________________
When____________________________________________________________________
If no, do you feel you need hearing aids?
□ No
□ Yes
Please check all that apply to your tinnitus.
Ear: □ Right ear
□ Left ear
□ Both ears
Frequency and duration: □ Constant
Tinnitus Sound: □ Ringing □ Buzzing
□ Periodic, how often and how long?____________
□ Chirping □ Static □ Pulsating □ Hissing
□ Other _______________________________________________________
How does your tinnitus affect your daily life? _______________________________________
B. Medical History
Do you have a history of ear infections?
□ No
□ Yes, please describe.__________________________________________________
Have you ever had surgery on/around your ears?
□ No
□ Yes, please describe.__________________________________________________
Do you have any family members with hearing loss or other ear-related issues?
□ No
□ Yes, please describe.__________________________________________________
Have you experienced any changes in your hearing after you took certain medication?
□ No
□ Yes, please describe.__________________________________________________
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Rev. 8/6/13
Do you have a history of noise exposure?
□ No □ Yes
□ Loud concert/music □ Farm equipment □ Power tools □ Industrial machinery
□ Firearms □ Military-related noise □ Other ____________________________________
Please check all that apply to any medical conditions you may have.
□ Diabetes □ High Blood Pressure □ Cancer □ Traumatic Brain Injury
□ Serious Infection □ Arthritis □ Stroke
□ Other ____________________________
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Rev. 8/6/13