Case History Adults Name(Required)Date(Required) MM slash DD slash YYYY Email(Required) Referred By(Required)Explain the reason of your visit?(Required)Briefly describe any medical condition you may have?(Required)Do you feel you have hearing problem? That also mean you hear but don't understand what people say?(Required) Yes No How would you rate your communication difficulty?(Required) Mild Moderate Severe Which ear is your better hearing ear?(Required) Right Left Same Don't Know Do you have any history or noise or music exposure?(Required) Yes No Do you have any history or noise or music exposure? plz describe?(Required)Do you have a history of hearing loss in your family?(Required) Yes No Have you ever had any type of ear surgery?(Required) Yes No Have you ever had any type of ear surgery? plz describe(Required)Do you currently have drainage from your ears?(Required) Yes No Do you have noises in your ear or brain (tinnitus)?(Required) Yes No Which ear?(Required) Left Right Both Don't Know Have you ever had chemotherapy?(Required) Yes No Have you ever had chemotherapy - For What?(Required)Have you ever had radiation therapy of the head, neck or ear?(Required) Yes No Do you wear hearing aids?(Required) Yes No Which ear?(Required) Right Left Both Which type of hearing aids?(Required) BTE RIE Custom Which type of hearing aids - custom?(Required)How long you have been wearing hearing aid?(Required)Please enter a number from 0 to 90.Any concerns regarding your current hearing aid?(Required)CAPTCHA Name(Required) First Last DOB(Required) MM slash DD slash YYYY Referred By:(Required)Please SelectENTSelfOther Medical ProfessionalMedical HistoryAre you having any ear or head related deformity from birth?(Required) Yes No Have you had/ having any of disorders mentioned below Diabetes High BP Thyroid Conditions Have you ever had any severe viral/bacterial infections?(Required) Yes No Have you ever taken any ototoxic drugs for any serious illness?(Required) Yes No Have you had any ear related or head surgery done?(Required) Yes No Have you had any head or brain tumor?(Required) Yes No Are you under any long term medication currently? If yes, mention it(Required) Yes No Are you under any long term medication currently please mention itGeneral Complaint ( Describe your Problem)(Required)Hearing Problem(Required) Yes No When did it start(Required)Which ear is your better hearing ear?(Required) Right Ear Left Ear Both Ear Are Equal Don't Know Did you had any history of Ear Infection Ear Drum Rupture Accident Involving Head Injury Dizziness or Spinning Sensation From When? How Many Episodes(Required)Do you work or worked in noisy environment?(Required) Yes No How long is your working hours in noisy environment? (in hours per day)(Required)Please enter a number from 1 to 24.Have you ever experienced Tinnitus( Ringing sound from ear or head)(Required) Yes No Which side are you hearing?(Required) Right Left Inside Head Is your hearing problem hindering you from communicating with people?(Required) Yes No Choose what fits your hearing of Speech.(Required) Can’t hear any one speaking even at a loud level, have to rely on completely lip reading Can hear speech if the person is talking loudly at ear level Can hear speech from front at moderate level, but not from back or side. Have problem only with low level speech and if person speaking from a distance Only have problem in hearing speech in presence of background noise Have intolerance to loud sounds that are okay for others. Have you ever had any type of ear surgery?(Required) Yes No Do you have a history of hearing loss in your family?(Required) Yes No Have you ever fitted with hearing aid?(Required) Yes No Age at which hearing aid was fitted.(Required)Please enter a number from 1 to 90.Are you currently using hearing aids?(Required) Yes No In which ear are you using hearing aids?(Required) Right Ear Left Ear Both Ears How many hours in a day do you use the hearing aid?(Required)Please enter a number from 1 to 24.If you have fitted and stopped using hearing aid, Explain what made you stop using it?(Required)What kind of speech problem are you facing? Unclear Speech Fluency Problem Voice Problem Post incidental (neurological /traumatic) Speech –Language error. Not Applicable Describe the problem in your own words.(Required)
