ADULT CASE HISTORY

HEARING

Date: ______

Center No. ______

Personal Information

Name / Date of Birth / Gender
(Last) / (First) / (Initial)
Address
(Street and Number) / (City) / (State)
Phone / (H) / (W) / Occupation
Married? / No. of children / Ages:
Referred by:
Address:

Information Concerning Problem

  1. How old were you when the hearing loss was called to your attention? ______
  2. What has been done about it? ______
  3. What do you feel caused your hearing problem? ______
  4. Have your ears ever been examined by a physician? ______List physician and dates:
    ______
  5. Has either ear ever pained and ached? ______When? ______
    Describe: ______
  6. Have you ever had draining ears? ______Which ear? ______How often? ______
    When was the last time? ______
  7. Has there been any obvious change in your hearing within the last six months? ______
    Within the last year? ______Last two years? ______
  8. Have you any allergies? ______Describe ______
  9. Do you every feel dizzy? ______How often? ______
  10. Does your hearing seem better on some days then others? ______
  11. Which do you feel is your better ear? ______Why? ______
  12. Do you have trouble following conversations in noisy areas?______
  13. Have you ever had a speech or language evaluation? ______
  14. Do you have trouble maintaining attention? ______Or are you easily distracted? ______

1

  1. Do loud sounds bother you? ______
  2. Do you have trouble hearing at the movies? ______Lectures? ______
    In a group? ______In talking to one person? ______TV? ______Radio? ______
    On the telephone? ______
  3. Have you ever exposed to loud noises? ______Describe: ______
    ______
  4. Do you have any ringing in your ears?______
    a) If so, is it constant or intermittent? ______
    b) If so, is it in one or both ears? ______
    c) If so, please describe the sound ______

Hearing Aid Information

  1. Have you ever worn a hearing aid? ______
  2. Do you wear one now? ______Model and make of aid worn ______
    ______
  3. When did you first start wearing a hearing aid? ______
  4. Date of purchase of present aid: ______
  5. By whom was the aid recommended? ______
  6. Has present aid been: Satisfactory? ______Unsatisfactory? ______
  7. How many hours a day do you wear your hearing aid? ______
  8. How often do you wear your hearing aid? ______

Occupational Information

  1. Has your hearing ever caused you to change jobs? ______
  2. Do you have any difficulty in your present occupation because of your hearing? Explain: ______
    ______
  3. Is it noisy where you work? ______Explain: ______
  4. Do you have any hobbies?______If so, please list them ______
    ______
    ______

1

  1. Has anyone in your family ever had a hearing problem? ______How related?______
  2. What caused their hearing loss? ______
  3. Do any of these relatives wear hearing aids? ______
  4. How long have they been hard of hearing? ______

Medical History

Indicate illnesses you have experienced:

Mumps ______Rickets ______

Scarlet Fever ______Noises in the ear ______

Influenza ______Earaches ______

Polio ______Allergies ______

Sinus ______Headaches ______

Measles ______Nausea ______

Meningitis ______Dizziness ______

Chicken Pox ______Drug/Chemotherapy ______

Pneumonia ______Cancer ______

Tonsillitis ______High Fever ______

Convulsions ______Concussion ______

Chronic Colds ______Loss of Consciousness ______

Surgery:

Tonsillectomy ______

Adenoidectomy ______

Middle ear surgery ______

Other ______

COMMENTS:

102 - B