Adult Case History
Name:
Date of Birth: / / Today's Date: / /
Reason for Today’s visit
Referred by
GENERAL MEDICAL
1. Have you had any of the following:
Kidney Disease………….. YES NO Hypertension…………… YES NO
Diabetes…………………. YES NO Visual problems………... YES NO
Cancer…………………… YES NO Sinus problems………… YES NO
Other (please list)
2. Are you taking any medications? YES NO
IF YES, which ones
3. Have you ever experienced head trauma? YES NO
4. Have you ever had surgery on your ear(s), nose, or throat? YES NO
HEARING (Please fill in the blanks or check where appropriate)
1. When did you first notice your hearing problem?
2. Was your change in hearing SUDDEN or GRADUAL?
3. Has your hearing become worse since you first noticed the problem?
YES
NO
4. Do you hear better in one ear than the other? YES NO
If YES, which ear is better? RIGHT LEFT
5. Does your hearing remain CONSTANT or FLUCTUATE?
6. Have you experienced any of the following:
YES NO Ear pain
BOTH
YES NO Plugged ear(s)
BOTH
YES NO Ringing/buzzing
If Yes: RIGHT LEFT
If Yes: RIGHT LEFT
If Yes: RIGHT LEFT
BOTH
YES NO Dizziness/Vertigo
8. Have you ever been exposed to loud noise (work, recreation, Military service)? YES NO
IF YES, please briefly explain
9. Has anyone in your family experienced hearing loss? YES NO
If YES, who?
10. Have you had your hearing tested before? YES NO
11. Have you ever worn hearing instruments? YES NO Currently? YES NO
12. Which situations do you have difficulty hearing?
