Patient Information

Fine Hearing Care PATIENT HISTORY INFORMATION

Name: Date:

Please state the reason(s) why you are here:

Do you have any of the following: (Circle all that apply)

A. Ringing in your ears	B. Dizziness	C. Drainage
D. Ear Pain	E. Fluctuating hearing loss	F. Sudden hearing loss
G. Fullness or pressure in the ears	H. Sinus/allergy problems	I. Trouble hearing clearly
J. Diabetes	K. Frequent Headaches	L. Heart disease
M. High blood pressure	N. Seizures	O. Temporomandibular Joint Syndrome (TMJ)
P. Childhood ear aches	Q. Ear surgery	R. Excessive ear wax
S. Exposure to loud sounds	T. Head trauma/unconsciousness	U. Hearing loss in the family
V. History of hearing loss	W. Other:

Current medication(s):

Please check the box which corresponds to your ability to hear in the situations listed and how often you are in that situation.

Listening situation	How well do you hear in this situation?	How often are you in this situation?
Quiet Room (1 or 2 people)	GOOD FAIR POOR □ □ □	A LOT SOME NOT □ □ □
Small Group (4 to 6 people)	□ □ □	□ □ □
Large Social Gathering	□ □ □	□ □ □
Restaurants / Dining Room	□ □ □	□ □ □
Meetings / Lectures / Church	□ □ □	□ □ □
Work place	□ □ □	□ □ □
Television	□ □ □	□ □ □
Car	□ □ □	□ □ □
Telephone	□ □ □	□ □ □
Cell Phone	□ □ □	□ □ □

On a scale of 1 to 10, where do you think you are regarding doing something about your hearing loss considering medical, psychological, emotional, financial, etc. factors)?

1 2 3 4 5 6 7 8 9 10
Not Motivated Very Motivated

What is your hearing aid experience?

□       I have a hearing device and use it regularly in the ___ right ear ___ left ear
□       I have a hearing device and ___ use it only occasionally or ___ don’t use it
□       I tried a hearing device, but returned it for credit.
□       I have inquired about hearing devices at another office(s), but did not purchase it at that time
□       I have never used a hearing device.
□       I do not think I need a hearing device.