Adult Case History

SECTION I:

Full Name*

First Last

Preferred Name

Address*

Street Address Address Line 2 City State ZIP Code

Secondary Address

Street Address Address Line 2 City State ZIP Code

Gender*

Date of Birth*

Home Phone*

Cell Phone*

Email*

May we use your email address to contact you for updates and classes?

Yes
No

How Were You Referred?

Employment Status

Your Occupation

Marital Status

Partner Name

First Last

Emergency Contact Name*

First Last

Relationship To Patient*

Emergency Phone*

Name of your primary care physician*

Have you seen a physician in the last 6 months?*

Yes
No

May we send a copy of your hearing test to your physician?*

Yes
No

List Any Major Health Conditions You Have*

List Any Prescription Medication You Are Taking*

List Any Over the Counter Medication You Are Taking*

SECTION II:

Do you presently or in the past have any of the following conditions? (Please check Yes or No)

Sudden hearing loss in one or both ears?*

Yes
No

Dizziness or balance problems?*

Yes
No

Pain in your ear(s)?*

Yes
No

Tinnitus (ringing in your ears)?*

Yes
No

History of noise exposure? (i.e. Loud music, gunfire, construction, power tools)*

Yes
No

Family history of hearing loss?*

Yes
No

History of ear surgery?*

Yes
No

Do you now wear, or have you ever worn hearing aid(s)?*

Yes
No

If Yes, how old are your current hearing aids?

Do you currently have any hearing difficulties? (With or without hearing aids) If YES, please proceed with SECTION III. If NO, check NO on SECTION III and submit the form.*

Yes
No

SECTION III:

What do you feel is causing your hearing problem?*

Does a hearing problem cause you to feel embarrassed when meeting new people?*

Yes
No
Sometimes

Do you have difficulty hearing when someone speaks in a whisper?*

Yes
No
Sometimes

Does a hearing problem cause you to have arguments with your family members?*

Yes
No
Sometimes

Do you feel that a hearing problem limits or hampers your personal or social life?*

Yes
No
Sometimes

Does a hearing problem cause you to attend favorite activities less often than you would like?*

Yes
No
Sometimes

Does a hearing problem cause you difficulty when listening to TV or radio?*

Yes
No
Sometimes

Is it difficult to hear conversations well in a restaurant or other noisy environment?*

Yes
No
Sometimes

By submitting this form you are acknowledging that you have read and understood our Privacy Policy

Comments

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SECTION I:

SECTION II:

SECTION III:

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