Home Grown Hearing > Forms

Name

Date

Open the calendar popup.

Date of Birth

Gender

Primary Language

Marital Status

Race

Ethnicity

Current Employment

Current Employer

Position

Highest Level of Education

Do you currently use recreational drugs

If yes what drugs

How often

Do you currently use tobacco

If yes what do you smoke

If yes amount per day

Do you currently drink alcoholic beverages

If yes how often

Do you experience hearing loss

If so which ear

If you experience hearing los which best describes it

When did you first notice your hearing loss

Have you ever had a hearing test

If so when

Which ear do you use to talk on the phone

Have you ever worn or tried a hearing aid

What type or style of hearing aid

Please describe your experience

Do you still experience any of the following with your current hearing aid

Some sounds are too loud
Sounds are too soft
Pain
Sounds are tinny or metallic
Ceaning hearing aid
Naturalness of sound
Trouble understing in quiet
Wind noise
Trouble using telephone
Feedback or whistling
Changing battery
Repair issues
Trouble understanding in noise
Do not like the appearance of aid
Do not like the sound of own voice
Cannot tell direction of sound
Battery life
Other

Check all the medial conditions that apply

Developmental Disorders/Delays
Dizziness or Unsteadiness
Ear Deformity
Ear Drainage
Ear Pain
Family History of Hearing Loss
History of Ear Infections
History of Ear Wax Buildup
History of Noise Exposure
Previous Ear Surgery
Tinnitus/Ringing/Noises in ears
Other

Does a hearing problem cause you to feel embarrassed when you meet new people

YesNoSometimes

Does a hearing problem cause you to feel frustrated when talking to members of your family

YesNoSometimes

Do you have difficulty when someone speaks in a whisper

YesNoSometimes

Do you feel handicapped by a hearing problem

YesNoSometimes

Does a hearing problem cause you difficulty when visiting friends or relatives or neighbors

YesNoSometimes

Does a hearing problem cause you to attend religious services less often than you would like

YesNoSometimes

Does a hearing problem cause you to have arguments with family members

YesNoSometimes

Does a hearing problem cause you difficulty when listening to TV or radio

YesNoSometimes

Do you feel that any difficulty with your hearing limits or hampers your personal or social life

YesNoSometimes

Does a hearing problem cause you difficulty when in a restaurant

YesNoSometimes

Please list major illnesses or surgeries or injuries or hospitalizations since birth and their dates

Have you experienced any of the following major medical conditions -- please check all that apply

List all allergies that you have

Major medical condition - check all that apply

AIDS/HIV
Diphtheria
High Blood Pressure
Mumps
Appetite Change
Encephalitis
High Fevers
Scarlet Fever
Arthritis
Fatigue
Influenza
Stroke
Blood Disorders
Genetic Disorders
Malaise
Tonsillitis
Cancer
Headaches
Malaria
Typhoid
Chicken Pox
Head Injury
Measles
Vascular Problems
Diabetes
Heart Problems
Meningitis
Other

Over the counter and prescription current medications

List immunizations

Eye Problems such as blurred vision or pain

YesNo

Nose or Throat or Mouth Problems such as trouble swallowing or nose bleeds or dental issues or pain

YesNo

Cardiovascular Symptoms such as hypertension or chest pain or swelling or palpitations

YesNo

Respiratory Symptoms such as shortness of breath or cough or wheezing

YesNo

Gastrointestinal Issues such as nausea or vomiting or weight changes or diarrhea or pai

YesNo

Musculoskeletal Symptoms such as joint pain or swelling or recent trauma

YesNo

Neurologic Symptoms such as numbness or headaches or seizures or muscle weakness

YesNo

Psychiatric Issues such as depression or anxiety or compulsions

YesNo

Endocrine Symptoms such as frequent urination or hot flashes

YesNo

Hemotologic Lymphatic Symptomssuch as bleeding gums or bruising or swollen glands

YesNo

Allergic or Immunologic Symptoms such as hives or asthma or itching or immune deficiency

YesNo

Patient Case History Form

Audiologic History

Medical History