Case History Adults

+91-11-4608 5246
[email protected]
Mon - Sat : 10:00 AM - 06:00 PM

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+91-11-4608 5245

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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

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

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

Have you ever had any type of ear surgery?(Required)

Yes

Have you ever had any type of ear surgery? plz describe(Required)

Do you currently have drainage from your ears?(Required)

Yes

Do you have noises in your ear or brain (tinnitus)?(Required)

Yes

Which ear?(Required)

Left

Right

Both

Don't Know

Have you ever had chemotherapy?(Required)

Yes

Have you ever had chemotherapy - For What?(Required)

Have you ever had radiation therapy of the head, neck or ear?(Required)

Yes

Do you wear hearing aids?(Required)

Yes

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)

Medical History

Are you having any ear or head related deformity from birth?(Required)

Yes

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

Have you ever taken any ototoxic drugs for any serious illness?(Required)

Yes

Have you had any ear related or head surgery done?(Required)

Yes

Have you had any head or brain tumor?(Required)

Yes

Are you under any long term medication currently? If yes, mention it(Required)

Yes

Are you under any long term medication currently please mention it

General Complaint ( Describe your Problem)(Required)

Hearing Problem(Required)

Yes

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

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

Which side are you hearing?(Required)

Right

Left

Inside Head

Is your hearing problem hindering you from communicating with people?(Required)

Yes

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

Do you have a history of hearing loss in your family?(Required)

Yes

Have you ever fitted with hearing aid?(Required)

Yes

Age at which hearing aid was fitted.(Required)

Please enter a number from 1 to 90.

Are you currently using hearing aids?(Required)

Yes

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)

Products

Cochlear Implant System
Hearing Aids
BAHA
Middle Ear Implant
Auditory Brainstem Implant

Services

Audiology
Adult
Speech And Language Therapy

SpHear Speech & Hearing Clinic

DELHI

G-32, LGF, Lajpat Nagar-III,
New Delhi – 110 024
Tel: +91-11-4608 5245
+91-11-4608 5246

PATNA

Rajender Nagar, Road Number-8,
Rajendra Nagar, Patna – 800 016
Tel: +91-612-267 2906,
Mob: +91-98350 22492

NOIDA

E 152, Basement, Sector-20,
Noida – 201 301
Tel: +91-120-422 5246
Tel: +91-120-422 5247

About SpHear Clinic

A clinic where we understand that addressing a patient’s unique listening needs is the key to helping him/her.
SpHear Clinic offers personalized hearing, speech and communication services, in addition to the latest hearing device technology. We are dedicated to …. Read More

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