Fillable Client Hearing Loss Questionnaire California State University, Fresno

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Client Hearing Loss Questionnaire California State University, Fresno

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California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive, M/S PH 80
Fresno, CA 93740-8019
(559) 278- 2422 (559) 278-5187 fax
Name___________________________________ Date _____________________
Do you suspect you have a hearing loss: Yes No
If yes, in which ear(s): right left both
Do you experience tinnitus (noise) in your ears: Yes No
If yes, in which ear(s): right left both
Do you currently have tinnitus: Yes No
If yes, what were the findings:_____________________________________________
Are there other family members who have a hearing loss: Yes No
If yes, whom and describe hearing loss:______________________________________
Have you ever tried hearing aids: Yes No
Describe any ear surgery, if applicable:______________________________________
______________________________________________________________________
----------------------------------------------------------------------------------------------------------
(Below is for clinician’s use)
**
500 Hz
1000 Hz
2000 Hz
4000 Hz
6000 Hz
8000 Hz
Right
Left
** Screened at _________________ dB HL
Comments:_____________________________________________________________
______________________________________________________________________
_____________________________
Student Clinician Signature
___________________________________
Supervising Audiologist Signature
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Client Hearing Loss Questionnaire California State University, Fresno

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Completed 22 May 2020

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