Have You Noticed Difficulty with Your Hearing? Yes Or No

Case History

Name: ______Age: ______Date: ______

What brought you here today?______Have you noticed difficulty with your hearing? Yes – or – No If yes: What have you noticed and for how long? ______When do you think your hearing loss began? ______Has your difficulty with hearing been gradual or sudden? ______Does your hearing difficulty affect both ears or just one? Right - Left - Both Do you have a greater difficulty hearing woman’s, men’s, or children’s voices? ______Are there situations where it is particularly difficult for you to follow conversations? Large groups? Noisy restaurants? Theater? Car? Other: ______Do people comment on the volume setting of your television? ______Do you frequently have to ask people to repeat? ______Has someone said that you speak too loudly in conversation? Yes – or – No

Do you have ringing (tinnitus) in your ears? Yes – or – No If yes: Right – Left – Both – Constant- Intermittent - Pulsating Sounds like: ______

Do you experience dizziness? Yes – or – No Lightheadedness – Off-Balance – Spinning – Please describe what you notice as it begins: ______

Is there a family history of hearing loss? If so who: ______

Do you have any history of exposure to noise such as: recreational activities, at work, military experiences? Other/Explanation______Please list Medications (may provide a list to be copied): ______

Have you had any experiences with hearing aids? Yes – or – No ______