Audiology Clinic, 200 S. Jordan Avenue, Bloomington, IN47405-7002
Adult Case History
Date:______
Name:______Age:______Birthdate:____-____-____ Sex: M F
Address:______Apt.#:______City:______State:______Zip:______
Home Phone: (_____)______Work Phone: (____)______E-Mail:______
Cell Phone: (_____)______
Referral Source:______Primary Care Physician:______
Emergency Contact: ______
IndianaUniversity Affiliation:
□ Faculty / Staff (□ Retired /□ Family) Department:______□ Student □No Affiliation
Veteran of the US Armed Forces: □ Yes □No When:______
1. Primary Complaint:______
2. Hearing Loss: □ Yes □No □ Unsure
Which Ear: □Right □ Left
Better Ear: □Right □ Left Age of Onset:______
Check if Applicable: □Progressive (□gradual / □ rapid) □ Fluctuant □ Sudden Onset
□ Family History Prior to age 50 ______Who: ______Relationship to You : ______
Situations that cause difficulty: (check all that apply) □ 1 on 1 □ in groups □ with background noise
□ at work or volunteer jobs □ at home □ at social events □ using the phone
□ watching television □ in the car Remarks:______
______
______
Do you use Sign Language? □Yes □No □ Sometimes
Will you need an interpreter? □ Yes □ No
3. Medical History: (check all that apply)
□ Head injury with unconsciousness (when:______)
□ Ear pain (□ Right / □ Left) Onset:______
□ Discharge from the ear (□Right / □Left) Onset:______How often:______
□Fullness or pressure (□ Right / □ Left)
□ Dizziness Onset:______How often:______
□Nausea Onset:______How often:______
History of Ear Infections: □ Yes □ No
Ear: □ Right □ Left □ Both Age of Onset:______Age of last infection:______
Treatment: ______
Remarks:______
Ear Surgery: □ Yes □ No
Ear: □ Right □ Left □ Both Date of Surgery: ______
Type(s) of Surgery: ______
Remarks:______
□ Tinnitus □ Right □ Left □ Both □ Constant □ Fluctuates
Describe: □ Hissing □ Ringing □ Buzzing □ Thumping □ Clicking □ Other:______
Irritation level: □ Mild □ Moderate □ Moderate-Severe □ Severe □ Non-Irritating
Remarks:______
□ Vertigo □ Positional □ Rotary □ Light-Headedness
Accompanying Symptoms: □ Nausea □ Change in or onset of tinnitus □ fluctuating hearing loss
□Fullness or Pressure □ Other:______
Treatment:______
Remarks:______
General Health: ______
______
Hospitalizations:______
______
Diseases:______
______
Current Medications:______
______
4. Noise Exposure:
□ Factory or Industrial noise □ Farm Equipment □ Guns, Military Weapons □ Power tools / Mowers
□ Very loud concerts □ Personal Music device □ Loud Musical Instruments □ Aircrafts
□Motorcycles / ATV’s
5. Previous Hearing Evaluation: □ Yes □ No
Where: ______When:______
** If you have had a previous Hearing Evaluation please include a copy of those results.
6. Hearing Aids: □ Currently Worn □ Worn in the past □recommended, but not worn □never worn
. Ear fit: □Right □Left □ Binaural *If not worn, why not? ______
______
Where purchased: ______When: ______
Consistency of use:______
Perceived Benefit: ______
Interested in pursuing new hearing aids? □ Yes □ No
Remarks: ______
______
7. Rehabilitation Services:
Speech Reading: When: ______Where: ______
Auditory Training: When: ______Where:______
Speech Therapy: When: ______Where: ______
Other: ______When: ______Where: ______
Additional Comments (evaluate your success in the above program):______
______
Was the program terminated: □Yes □No Why: ______
______
8. Educational-Vocational History
Last grade completed? ______
Are you currently enrolled in any educational program? Yes No
If yes, then what type of program? ______
Is English your first language? Yes No If not, what is your first language?______
Are you currently employed? Yes No Occupation (previous or current)?______
Describe any hearing related work problems:______
______
Are you planning on returning to some type of work? Yes No
Will you need special training or help? Yes No
Have you applied to the Division of Vocational Rehabilitation (DVR) for assistance? Yes No
If “Yes” what is your counselor’s name? ______
DVR Address:______
DVR Telephone number: ( )______
INSTRUCTIONS
The purpose of this survey is to identify the problems your hearing loss may be causing you. Answer each question what appears below, by checking “Yes”, “Sometimes” or “No”. Do not skip a question if you avoid a situation because of a hearing loss. IF you use a hearing aid, please answer the way that you hear WITH OUT the hearing aid.
1. Does a hearing problem cause you to
feel embarrassed when meeting new people? □ Yes □ Sometimes □ No
2. Does a hearing problem cause you to feel
frustrated when talking to friends or
members of your family? □ Yes □ Sometimes □ No
3. Do you have difficulty hearing when
someone speaks in a whisper? □ Yes □ Sometimes □ No
4. Do you feel handicapped by a hearing
problem? □ Yes □ Sometimes □ No
5. Does a hearing problem cause you
difficulty when visiting friends,
relatives or neighbors? □ Yes □ Sometimes □ No
6. Does a hearing problem cause you to
attend religious services less often than
you would like to? □ Yes □ Sometimes □ No
7. Does a hearing problem cause you to have
arguments with friends or family members? □ Yes □ Sometimes □ No
8. Does a hearing problem cause you difficulty
when listening to T.V. or radio? □ Yes □ Sometimes □ No
9. Do you feel that any difficulty with your hearing,
limits or hampers your personal and social life? □ Yes □ Sometimes □ No
10. Does a hearing problem cause you difficulty
in a restaurant with relatives or friends? □ Yes □ Sometimes □ No
Client Signature:______Date:______
Please bring completed forms with you to your appointment. Thank you.