Adult Case History SECTION I:Full Name* First Last Preferred NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*Date of Birth* Date Format: MM slash DD slash YYYY 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 StatusYour OccupationMarital StatusPartner 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?*YesNoMay we send a copy of your hearing test to your physician?*YesNoList 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?*YesNoDizziness or balance problems?*YesNoPain in your ear(s)?*YesNoTinnitus (ringing in your ears)?*YesNoHistory of noise exposure? (i.e. Loud music, gunfire, construction, power tools)*YesNoFamily history of hearing loss?*YesNoHistory of ear surgery?*YesNoDo you now wear, or have you ever worn hearing aid(s)?*YesNoIf 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.*YesNoSECTION III:What do you feel is causing your hearing problem?*Does a hearing problem cause you to feel embarrassed when meeting new people?*YesNoSometimesDo you have difficulty hearing when someone speaks in a whisper?*YesNoSometimesDoes a hearing problem cause you to have arguments with your family members?*YesNoSometimesDo you feel that a hearing problem limits or hampers your personal or social life?*YesNoSometimesDoes a hearing problem cause you to attend favorite activities less often than you would like?*YesNoSometimesDoes a hearing problem cause you difficulty when listening to TV or radio?*YesNoSometimesIs it difficult to hear conversations well in a restaurant or other noisy environment?*YesNoSometimesBy submitting this form you are acknowledging that you have read and understood our Privacy PolicyEmailThis field is for validation purposes and should be left unchanged.
