Confidential Patient History
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Have you seen a doctor in the past 6 months?
Have you seen a doctor specializing in diseases of the ear?
Have you ever had your hearing tested?
Have you ever had any type of ear surgery?
Do you take medicine every day?
Do you have any other medical conditions?
Drainage from the ear
Sudden or rapid hearing loss in the past 90 days
Acute or chronic dizziness/vertigo
Ringing or buzzing (tinnitus) in either ear
If yes, which ear?
Which is your poorer ear?
Have you ever seen a doctor for wax removal?
Do you have a history of noise exposure (industrial, military or Recreational)?
Understanding conversation
Hearing in a crowd
Hearing on the telephone
Which ear do you use on the phone?
Hearing or understanding the television
Does anyone else in your family have a hearing problem?
Do you now or have you ever worn a hearing aid?
Are you ready for help if a hearing loss is discovered?