CALIFORNIA STATE UNIVERSITY, FRESNO
Speech and Hearing Clinic
AUDIOLOGY CASE HISTORY – ADULT
Name___________________________________ DOB________________ Gender__________
Occupation_____________________________ Referral _______________________________
Statement of the problem________________________________________________________
What do you think caused the problem?_____________________________________________
Have you ever had a hearing evaluation?___________ Where and when?__________________
Audiological History
Do you suspect you have a hearing loss? ___________ If so, describe ____________________
How old were you when you first suspected a hearing loss?_____________________________
Has it changed since its onset?_______ Does your hearing change from day to day?__________
Does your hearing loss interfere with your work?______ Explain_________________________
Is the speech of your family clear to you?________ Explain_____________________________
Is the speech of others clear to you in a noisy room?_________ Explain __________________
Have you ever tried a hearing aid?________ What type?_____________ Which ear?_________
How long?_________ Are you satisfied with your hearing aid(s)?_______ Explain__________
_____________________________________________________________________________
Medical History
What other medical problems do you have?_____________________________________
Do you get dizzy?__________ Describe your dizziness (lightheaded, off balance, spinning, etc.)
___________________________________________How long does it last?________________
How often does it occur?________ Do you get nauseated with the dizziness?_______________
Do you have some warning before a dizzy spell?_______ Explain:_______________________
Describe any noise (tinnitus) in your ears______________________ Which ear?____________
When is it most noticeable?___________________ How long have you had it?_____________
Do you have any numbness or tingling in your face?_________ Which side?_______________
Did you notice any hearing difficulties after having measles? ________, mumps?___________,
scarlet fever? ____________,chicken pox? _________, shingles? ____________
Have you ever taken any of the following drugs? streptomycin_______, vancomycin ________,
gentamicin ______, cisplatin _______, carboplatin _______, any diuretic (Lasix) _______
Other History
Have you ever worked in a noisy place? __________ If so, where?_______________________
For how long?__________ How often did you wear hearing protection?___________________
What other forms of noise exposure have you had (concerts, firearms, music, construction,
carpentry, aircraft, etc.) _________________________________________________________
Tell me: The types of problems you have experienced because of your hearing loss? ________
_____________________How your listening difficulties (hearing loss) affects your everyday
life? ___________________The kinds of activities that you like to do?__________________
The problems you experience in performing these activities that are associated with your
listening difficulties (hearing loss)? ____________________________________________
The activities that you find more difficult to do now than in the past because of your listening
difficulties (hearing loss)? ____________________________________________________
The activities that you would like to do that you have stopped doing because of your listening
difficulties (hearing loss)? _____________________________________________________
Any new activities that you would like to try? _______________________________________
