[PDF]Adult History Form - Rackcdn.comhttps://105b31079a1ba381f52e-ac2ec5114feb632a1114f20df0e72453.ssl...
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Medical History:
Name: ____________________________DOB: ________
What is the primary reason for your visit today? _____________________________________________________ Have you had or currently have any of the following conditions: Please Circle High Blood Pressure Heart Disease Stroke Arthritis Dementia General Anesthesia Meningitis Kidney Disease Vision Impairment
Measles Diabetes Reduced Dexterity
Cancer
Do you currently have an implantable device such as a pacemaker, cardioverter defibrillator or cardiac resynchronization device? ______________________________________________________________________ Please list your current medications: ______________________________________________________________ ____________________________________________________________________________________________ Do you have trouble hearing? If yes, RIGHT LEFT BOTH Better ear? _______________________________ Describe your hearing loss: SUDDEN GRADUAL FLUCTUATING? _____________________________________ When did you first notice difficulty hearing? _______________________________________________________ Has your hearing become worse since you first noticed the problem? ___________________________________ When was your last hearing evaluation? _____________Results? ______________________________________ Have you ever had ear, nose or throat surgery? If yes, briefly explain: ___________________________________ Have you had any hospitalizations/surgeries in the last 5 years? _______________________________________ Have you experienced any ear pain, drainage, pressure, or fullness? If yes, briefly explain: __________________ ___________________________________________________________________________________________ Do you experience ringing, buzzing or other noises in your ears? If yes, RIGHT
LEFT
BOTH
If yes, is the tinnitus sound: PERSISTENT INTERMITTENT OCCASIONAL? Describe: _______________________ Have you experienced any dizziness or vertigo? If yes, briefly explain: __________________________________ Has anyone in your family experienced hearing loss? If yes, who/what age? ______________________________ Have you ever been exposed to excessive noise? Please describe: ______________________________________ Have you ever experienced head trauma? Please describe: ___________________________________________ Have you ever worn hearing devices? _____ What type? _____________________________________________ How long? _______Are you satisfied with the performance? __________________________________________ Type of Cell Phone: Apple iPhone Google/Android Flip Phone None
Please answer the following questions about your hearing ability: Does a hearing loss cause you to feel embarrassed when meeting new people?
Yes
Sometimes No
Do you have difficulty understanding speech on a cell phone or landline or TV?
Yes
Sometimes No
Do you sometimes feel that people are mumbling or not speaking clearly?
Yes
Sometimes No
Does hearing difficulty cause you to be frustrated when talking to your family?
Yes
Sometimes No
Do you find it difficult to follow conversation in a noisy restaurant or group?
Yes
Sometimes No
Does hearing loss cause difficulty when socializing with friends, relatives or neighbors?
Yes
Sometimes No
Do you have trouble understanding soft or whispered speech?
Yes
Sometimes No
Do you find it difficult to understand a speaker at a public meeting or religious service? Yes
Sometimes No
Do you find yourself asking people to speak up or repeat themselves?
Yes
Sometimes No
Do you feel that difficulty hearing interferes with your work, social or personal life?
Yes
Sometimes No
Please tell us anything else you would like to share about your hearing: _______________________________ _________________________________________________________________________________________