Medical and Hearing history
Name:
*
Date of Birth
*
-
Month
-
Day
Year
Date
Medical History - Check all that apply
Arthritis
Measles
Multiple Sclerosis
Diabetes
Heart Problems
High Blood Pressure
Head Injury
Stroke
Blood Disorder
Meningitis
Cancer
Are you taking medication for any of these?
Hearing loss:
Left Ear
Right Ear
Both
Family history of hearing loss
Yes
No
If Yes, who?
History of noise exposure?
Yes
No
If yes:
Workplace
Firearms
Music/Concerts
Tinnitus (ringing/buzzing in ear)
Yes
No
If yes, is the noise:
Mild
Moderate
Severe
Sudden hearing loss?
Yes
No
If yes, which ear:
Left Ear
Right Ear
Both
Is the hearing worse in one ear?
Yes
No
If yes, which ear:
Left
Right
Both
Please check areas where you want improvement
Conversations in quiet with 1 or 2 people
Conversations in noise with 1 or 2 people
Conversations in a group in quiet
Conversations in a group with noise
Television or radio
Home Telephone
Cell Phone
Cell Phone on speakerphone
Cell Phone not on speakerphone
Hearing the phone ring
Hearing the door bell or a knock
Increasing social contact
Feeling embarrassed
Feeling left out
Church or meeting
Current Hearing Aid Users Only
How long have you worn hearing aids for?
How old is your current hearing aid(s)?
Inserting in my ears is
Easy
Manageable
Difficult
Changing batteries is
Easy
Manageable
Difficult
Adjusting the volume is
Easy
Manageable
Difficult
N/A
Cleaning is
Easy
Manageable
Difficult
Accessory use (including cell phone) is
Easy
Manageable
Difficult
N/A
Submit Medical and Hearing History Form
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