THE HEARING SOLUTION - New Patient History Form

Rows	Yes	No
Do you have a better hearing ear?
Have you experienced a sudden/progressive hearing loss in the last 90 days?
Have you had any ear surgeries?
Do you suffer from ear pain?
Do you have pressure or fullness in your ears?
Have you had chronic ear infections?
Do you have drainage from your ears?
Do you have a history of head trauma?
Do you have a family history of hearing loss?
Do you notice ringing/buzzing/tinnitus in your ears?
Do you have a history of dizziness/vertigo?
Do you have a history of excessive noise exposure?
Do you have a history of wax build up?

Please rate your present hearing ability:

	1	2	3	4	5	6	7	8	9	10

1 is Perfect hearing, 10 is Severe hearing loss

What is the main reason you would like to improve your hearing and communication ability?

Please rate how motivated you are to use hearing aids:

	1	2	3	4	5	6	7	8	9	10

1 is Not Motivated, 10 is Very Motivated

How much difficulty do you have hearing in the following situations?

Rows	No Difficulty	Slight Difficulty	Moderate Difficulty	Very much difficulty	Not Relevant
One on one conversations
Conversations in small groups
Conversations in large groups
Outdoors
Concerts/Theaters
Place of worship/lecture halls
Watching TV
In a car
Landline Phone
Cell Phone
Restaurants

New Patient History Form