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Chief Complaint (Choose one)
Hearing Loss (Right Ear)
Hearing Loss (Left Ear)
Hearing Loss (Both Ears)
Difficulty Hearing (in Quiet)
Difficulty Hearing (in Noise)
Telephone (Right Ear)
Telephone (Left Ear)
How long have you noticed this difficulty?
Is this a problem due to work injury or exposure?
If so, Date of Injury
Do you feel your hearing is changing?
How would you describe the change?
Have you ever been exposed to loud noise, either recently or in the past?
Select all that apply:
Have you seen an ear, nose and throat physician?
If so, who did you see?
Have you ever had surgery that may have affected your hearing?
Is there a history of hearing loss in your family?
If so, who?
Have you ever had an ear infection?
If yes, was it:
As a Child
As an Adult
Have you, in the past 10 years, experienced chronic or acute dizziness, light-headiness, or vertigo?
If yes, please describe.
Do you take any prescription medications? *Required for medicare patients
Please list any medication taken, the reason for the medication and the dosage.
Medicare patients only: Are you a smoker?
Please check off any of the following that you currently have or have had in the past:
High Blood Pressure
If a hearing aid was recommended for you, please rank the following in order of importance.
(1 is most important, 4 is least important)
Improved hearing in quiet
Improved hearing in noise
If you are currently using a hearing aid, or have in the past, please answer the following:
Which ear is aided?
How long have you used a hearing aid?