Adult Hearing Health History Form

Name *

Date of Birth *

Gender *
MF

Phone # *

Email

Employer *

Occupation *

Primary Care Physician *

What is the reason for your visit (primary concern)? *

How did you hear about us?*
TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther

Do you feel you have hearing loss? *
YesNo

If YES, is one ear worse? *
RightLeftBoth the Same

Has your hearing loss occurred gradually or very suddenly? *
GradualSudden

When did you first notice your hearing loss? *

Have you ever had your hearing tested? *
YesNo

If YES, when? *

If YES, result? *

Have you ever worked in a loud place or participated in loud activities? *
YesNo

If YES, explain? *

Do you use hearing protection at work or during these loud activities? *
YesNo

Do you hear ringing or buzzing in your ears (tinnitus)? *
YesNo

If YES, which ear(s)? *
RightLeftBoth

If YES, does it bother you? *
YesNo

Is the tinnitus constant or occasional?
ConstantOccasional

When did your tinnitus begin? *

What does your tinnitus sound like? *

Does anyone else in your family have difficulty hearing? *
YesNo

If YES, who? *

Do you have a history of ear infections or ear surgery? *
YesNo

If YES, Explain? *

Have you ever seen a doctor for an ear-related issue? *
YesNo

If YES, name of doctor? *

Date of visit *

Pain in your ears? *
YesNo

If YES, which ear(s)? *
RightLeftBoth

Drainage from your ears? *
YesNo

If YES, which ear(s)? *
RightLeftBoth

Dizziness or imbalance? *
YesNo

If YES, it is: *
ConstantOccasional

When did it begin and please describe? *

Do you have any chronic medical conditions? *
YesNo

If YES, list: *

Do you have any allergies (ex. Latex, Acrylic, dyes)? *
YesNo

If YES, list: *

Do you take any blood thinners? (ex. Coumadin, Plavix, Warfarin, aspirin) *
YesNo

Have you used a tobacco product (ex. cigarette, cigar, smokeless tobacco) one or more times in the past 24 months? *
YesNo

If yes, how often have you used a tobacco product in the past 24 months? *

If yes, what type(s) of products have you used? *

Do you currently take any medications or vitamins? *
YesNo

Please list all your medications, vitamins, etc (name, dosage, route (mouth, injection, etc.), reason) *

Name

Dosage

Frequency

Route

Reason

If you take more than six medications, please bring a detailed medication list to your appointment).

What motivated you to set the appointment for your hearing test? *

What is your hearing aid experience? (Check all that apply) *
I have a hearing aid and use it regularly in my right earI have a hearing aid and use it regularly in my left earI have a hearing aid and use it regularly in both earsI have inquired about hearing aids at another office but did not purchase at the timeI have a hearing aid, but don’t use it or only use it occasionally.I have never used a hearing aid.I have tried a hearing aid but returned it.None of the above

Please list the top 3 situations you would most like to hear better. Be as specific as possible. *

Please rank your most important consideration regarding hearing aids with 1 as most and 4 as least important.

On a scale of 1 to 10, with 1 being "not at all ready" and 10 being "very ready", how ready are you to get help for your hearing difficulty?*
12345678910

What office are you going to your for your appointment? *
AmherstWilliamsvilleOrchard ParkTonawanda

Signature *

Date *