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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? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Page 1 of 3 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.__________________________________________________ Page 2 of 3 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 ____________________________ Page 3 of 3 Rev. 8/6/13