Hearing Questionnaire & Audiology Patient History Form 

 

Name:__________________________________ Birth Date:__________________________

Preferred name:____________________________

Spouse name/Significant other name: ____________________________________________

Phone (Home):___________________________ Phone (Cell/Work):___________________

Address:_______________________________ City:________________ Zip Code:________

Email Address:_______________________________________________________________

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: ________________________________________________________

 

Hearing Sensitivity:

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? _________

 

Tinnitus:

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? _____

 

Balance:

Do you feel: Off balance □ Lightheaded □ a spinning sensation □

If yes, when was the onset? __________________________________

 

Trauma:

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 □ ____________________________________________________________________________

 

Family History:

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:

(1)___________________________________________________________________

(2)___________________________________________________________________

(3)___________________________________________________________________

 

P: (727-289-1212)  Fax:  (727-289-9901)   Email:  info@hearherefl.com

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