Hearing Questionnaire & Audiology Patient History Form
Name:__________________________________ Birth Date:__________________________
Spouse name/Significant other name: ____________________________________________
Phone (Home):___________________________ Phone (Cell/Work):___________________
Address:_______________________________ City:________________ Zip Code:________
Primary Care Physician:_______________________________________________________
Address and phone number:_____________________________________________________
How did you hear about the clinic? □ Doctor Referral □ Friend, word of mouth, relative □ Post Card □ Letter of invitation □
Newspaper □ Other _____________________________________
Reason for today’s visit: ________________________________________________________
Do you have difficulty hearing or understanding in the □ Right ear □ Left ear
Do you have an ear you feel is worse? Right □ Left □ No □
Was the hearing loss □ GRADUAL in onset or □ SUDDEN in onset?
If gradual, how long has it been getting worse? _________________________ If sudden, what were you doing just prior to it getting worse? (illness, cancer treatment, car accident, etc.) ___________________________________
Have you had your hearing tested before? yes □ no □
Hearing Instrument Use:
Have you ever worn hearing aids before? yes □ no □ If yes, what kind? __________________
How many years? _________
Do you have noises in your ears? yes □ no □
If yes, is the sound in the right □ or left □ ear?
Describe the sound:______________________________________
Is the sound constant □ or does it come and go □?
Does the noise keep you from falling asleep at night? yes □, no □
On a scale of 1 (no impact) to 10 (ruined), how does it affect your life? _____
Do you feel: Off balance □ Lightheaded □ a spinning sensation □
If yes, when was the onset? __________________________________
Have you ever had a severe injury to your head? yes □ no □
Have you ever had: Punctured eardrum □ Ear surgery □ Ear pain □ Ear infections □ Ear drainage □ Noise exposure: Have you ever been exposed to: □ Gun fire/explosions □ Power tools □ Lawn mower □ Occupational noise □ Other ____________________________________________________
If yes to any of the above, do you use hearing protection? yes □ no □
Were you in the military? yes □, no □ ____________________________________________________________________________
Does any member of your family have a hearing loss? yes □ no □ ?
If yes, who?_________________________________________________
Do you know the cause of their hearing loss? yes □ no □
Medications: Have you ever taken a medication that your doctor said may have an effect on your hearing? yes □, no □
Have you ever taken an anticancer (chemotherapy) drug? yes □, no □
If yes, was your hearing monitored during that time? yes □, no □
List the specifically the top three situations where you would most like to hear better:
P: (727-289-1212) Fax: (727-289-9901) Email: firstname.lastname@example.org
Mary Burton, Au.D., Doctor of Audiology – Alina Linthicum, Au.D., Doctor of Audiology.
Address: 502 Pasadena Ave. South., St Petersburg, FL 33707
Hours: Monday – Friday 8-4:30 pm