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Adult Case History Form

Name*
First Last
Today's Date*
MM
DD
YYYY
DOB*
MM
DD
YYYY
Gender*
- Male
- Female
Primary Language*
- English
- Spanish
- French
Current Employer*
Occupation*
Employment Status*
- Full-Time
- Part-Time
- Retired
- Unemployed
- Stay At Home Parent
- Student
Highest Level of Education*
- High School
- Associate Degree
- Bachelor's Degree
- Graduate of Professional Degree
- Some College
Do you currently use tobacco?*
- Yes
- No
Amount Per Day*
Type*
- Cigarettes
- Cigars
- Pipe
- Smokeless tobacco
Do you currently drink alcoholic beverages?*
- Yes
- No
How often?
- Daily
- Weekly
- Monthly
- Occasionally
- Rarely
Do you currently use recreational drugs*
- Yes
- No
What:*
How often?*
- Daily
- Weekly
- Monthly
- Occasionally
- Rarely
Audiologic History
Do you experience hearing loss?*
- Yes
- No
Which ear do you experience hearing loss?*
- Right
- Left
- Both
Please describe your hearing loss*
- Gradual
- Fluctuating
- Sudden
When did you first notice your hearing loss?*
What do you think caused the hearing loss?*
Have you ever had a hearing test?*
- Yes
- No
When did you have your hearing test?*
Which ear do you use on the phone?*
- Right
- Left
Have you ever worn a hearing aid?*
- Yes
- No
Where have you worn a hearing aid?*
- Right
- Left
- Both
What type and style of hearing aid?*
Please describe experience with your hearing aid*
Please check all medical conditions that apply:
- Developmental disorder/delay
- Dizziness/Unsteadiness
- Ear Deformity
- Ear Drainage
- Ear Pain
- Family history of hearing loss
- History of ear infections
- History of wax buildup
- History of noise exposure
- History of ear surgery
- Tinnitus/Ear noises
- Other
Explain developmental disorder/delay*
Dizziness/Unsteadiness is accompanied by:*
- Nausea
- Vomiting
- Ear noises
Ear Deformity*
- Right
- Left
- Both
Ear Drainage*
- Right
- Left
- Both
Ear Pain*
- Right
- Left
- Both
Who in your family history with a hearing loss?*
History of ear infections*
- Right
- Left
- Both
When were the ear infections?*
Describe history of noise exposure*
Ear surgery*
- Right
- Left
- Both
When was the ear surgery?*
Tinnitus/Ear noises*
- Right
- Left
- Both
Frequency of the Tinnitus/Ear noises*
Describe other medical history*
Does a hearing problem cause you to feel embarrassed when you meet new people?*
- Yes
- Sometimes
- No
Does a hearing problem cause you to feel frustrated when talking to members of your family?*
- Yes
- Sometimes
- No
Do you have difficulty when someone speaks in a whisper?*
- Yes
- Sometimes
- No
Do you feel handicapped by a hearing problem?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?*
- Yes
- Sometimes
- No
Does a hearing problem cause you to attend religious services less often than you would like?*
- Yes
- Sometimes
- No
Does a hearing problem cause you to have arguments with family members?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when listening to TV or radio?*
- Yes
- Sometimes
- No
Do you feel that any difficulty with your hearing limits or hampers your personal or social life?*
- Yes
- Sometimes
- No
Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?*
- Yes
- Sometimes
- No
Medical History
Please list any other illnesses, injuries, hospitalizations, or surgeries and their date(s) of occurrence:
Occurrence Date
Allergies (food, plastics, medications, etc):
Have you been immunized?*
- Yes
- No
For what disease(s)?*
Have you experienced any of the following medical conditions?
- AIDS/HIV
- Appetite change
- Arthritis
- Blood disorders
- Cancer
- Chicken pox
- Diabetes
- Diphtheria
- Encephalitis
- Fatigue
- Genetic disorders
- Head injury
- Headaches
- Heart Problems
- High blood pressure
- High fevers
- Influenza
- Malaise
- Malaria
- Measles
- Meningitis
- Mumps
- Scarlet fever
- Stroke
- Tonsilitis
- Typhoid
- Vascular problems
- Other
Please mark all medical symptoms that apply:
- Allergic/immunologic (hives, asthma, itching, immune deficiency)
- Cardiovascular (chest pain, swelling, palpitations)
- Endocrine (frequent urination, hot flashes)
- Eye problems (blurred vision, pain)
- Gastrointestinal (nausea, vomiting, weight change, diarrhea, pain)
- Hemotologic/lymphatic (bleeding gums, bruising, swollen glands)
- Musculoskeletal (joint pain, swelling, recent trauma)
- Neurological (numbness, headaches, seizures, muscle weakness)
- Nose, Throat, or Mouth Problems (swallowing, nose bleeds, dental issues, pain)
- Psychiatric (depression, anxiety, compulsions)
- Respiratory (shortness of breath, coughing, wheezing)
I certify this information is true and correct to the best of my knowledge.*
- I will notify you of any changes in the above information. I authorize the release of any medical information necessary to provide treatment and bill my insurance.
Name*
Date*
Date Format: MM slash DD slash YYYY
Email*
Prove Your Humanity

Δ

(317) 620-1897

Adult Case History Form

Audiologic History

Medical History

Office Hours

Monday - Thursday 9:00 am - 5:00 pm
Friday 9:00 am - 12 Noon
Additional times are available by appointment.

Occurrence	Date

(317) 620-1897

Adult Case History Form

Audiologic History

Medical History

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Office Hours

Monday - Thursday 9:00 am - 5:00 pmFriday 9:00 am - 12 Noon Additional times are available by appointment.

Monday - Thursday 9:00 am - 5:00 pm
Friday 9:00 am - 12 Noon
Additional times are available by appointment.