Hearing Health Questionnaire
ADVERTISEMENT
1Hearing Health Questionnaire
Date: _______________________
Background Information
Name: ___________________________________________________________ Date of Birth: ______________ Age: ______
What is the reason or purpose of today’s visit? ________________________________________________________________
Who encouraged you to have your hearing tested? ____________________________________________________________
What are you hoping to achieve as a result of this visit? _________________________________________________________
Symptoms
Have you been having trouble hearing recently? YES / NO. If yes, when did it begin? _____ Years ago, or, _____ Months ago.
Do you currently wear hearing aids? YES / NO. If yes, when did you purchase them? _________________________________
Do you have any of the following? (PLEASE CIRCLE ALL THAT APPLY):
Acute or recurring
Sudden or recent
Ear drainage
Ear pain
Punctured eardrum
dizziness
hearing loss
Ear pressure or fullness
Ears popping
Diabetes
Skin problems
Allergies
Have you ever seen a physician concerning an ear problem? YES / NO. If Yes, how long ago? ____Years ago. What was the
nature of the problem? ______________________________________________________. Was surgery performed? YES / NO.
Do you have tinnitus (ringing or noise in ears or head)? YES / NO. If yes, for how long? ____________.
Is it (please circle): CONSTANT / INTERMITTENT / EQUAL IN BOTH EARS / MORE IN ONE EAR / ONLY IN ONE EAR
Family History
Have any of the following blood relatives had any degree of hearing difficulty? (PLEASE CIRCLE ALL THAT APPLY):
Mother
Mother’s mother
Mother’s father
Mother’s sibling(s)
Sister
Father
Father’s mother
Father’s father
Father’s sibling(s)
Brother
Does your spouse or partner have hearing difficulty? YES / NO. Does your child(ren) have hearing difficulty? YES / NO.
Have any of the above mentioned individuals had hearing aids? YES / NO.
Have any blood relatives have permanent hearing loss beginning in childhood? YES / NO. Ear surgeries? YES / NO.
Noise Exposure
Have you had noise exposure from? (PLEASE CIRCLE ALL THAT APPLY):
Work noise
Military
Factory
Truck driving
Wood working
Races
Farming
Landscaping
Loud music
Shooting
Fireworks
Other: ________
Medical History
Do you have a history of any of the following? (PLEASE CIRCLE ALL THAT APPLY): Ear infections | Middle ear fluid | Fluctuating
hearing levels | Swimmer’ ear | Eardrum perforation | Head injury | Ear tubes | Skin cancer on ears | High blood pressure |
high cholesterol (taking cholesterol meds Y / N) | Cancer | Chemotherapy | Ototoxic drugs | Heart disease | heart attack |
taking blood thinners | Stroke | TIA or mini-stroke | Artery or vascular disease | diabetic neuropathy | wound healing difficult
Pacemaker | Genetic condition | Vision problem not corrected by lenses | Other: ____________________________________
Please provide a list of current medications including dose, frequency, and route (oral or injection):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life