1520 Wakarusa Drive
Suite B
Lawrence, KS 66047
www.kawvalleyhearing.com
Patient History Form
Patient Name: __________________________________
DOB: __________________
Date: __________________
Primary Concerns: __________________________________________________________________________________
__________________________________________________________________________________________________
How or when did your problem first occur? ______________________________________________________________
Have any of these concerns been previously evaluated? ___________________________________________________
o
o
o
o
o
o
 Do you have any of the following symptoms? Please indicate which ear.
Difficulty Hearing
Left Ear
Right Ear
Both
Ear Pain
Left Ear
Right Ear
Both
Ear Drainage
Left Ear
Right Ear
Both
Ear Fullness / Pressure
Left Ear
Right Ear
Both
Tinnitus (Noise in your head/ears)
Left Ear
Right Ear
Both
Dizziness? Please elaborate: ___________________________________________________________________

o
o
o
o
o
o
o
o
o
o
o
o
o
o
Please indicate any of the following, that you currently have or have had in the past:
Vision Loss
o Sinusitis
o Meniere’s Disease
Peripheral Neuropathy
o CMV
o Migraines
Diabetes
o Multiple Sclerosis
o Ear Infections
High Blood Pressure
o Parkinson’s Disease
o Measles and Mumps
Heart Condition
o Tingling / Numbness in Face
o Hepatitis
Meningitis
Family History of Hearing Loss: Who? ___________________________________________________________
Head Injury? Date and symptoms: ______________________________________________________________
Bell’s Palsy: Affected Side: ____________________________________________________________________
Stroke / TIA: Affected Side: ___________________________________________________________________
Neurological Disorder: _______________________________________________________________________
Ear Trauma / Surgery: Ear - Right / Left
Type: ________________________________________________
MRI / CT of Head? Date: _____________ Location: _____________________________________________
Other: ____________________________________________________________________________________
1520 Wakarusa Drive
Suite B
Lawrence, KS 66047
www.kawvalleyhearing.com
Patient History Form

o
o
o
o
Difficulty in Quiet Environments
Difficulty in Noisy Environments
Trouble Understanding Television
Trouble Understanding on the Telephone

o
o
o
o
o
o
o
o
o
o
Hearing Loss Began Suddenly
Hearing Loss Has Progressed Gradually
Fluctuations in Your Hearing
History of exposure to loud noise
If you have tinnitus (noise in your head / ears), please answer the following:
Did your tinnitus begin suddenly?
Yes
No
Does anything make your tinnitus better?
Yes
No
o If yes, please describe: _______________________________________________________________
Does anything make your tinnitus worse?
Yes
No
o If yes, please describe: _______________________________________________________________
Is your tinnitus constant?
Yes
No
Describe your tinnitus: ______________________________________________________________________
Did any specific incident cause the onset of the tinnitus?
Yes
No
o If yes, please describe: ________________________________________________________________

o
o
o
o
o
o
If you have difficulty hearing, please mark all that apply:
If you have dizziness or vertigo, please answer the following:
Do you have dizziness or vertigo?
Is your dizziness / vertigo constant?
Do you feel off balance?
Have you fallen?
Do you use a cane or a walker to assist in mobility?
Have you hit your head?

Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Please list all current medications you routinely take, both prescription and over the counter.
(use back of page if needed)
Medication
For
_________________________________________________________
____________________________
_________________________________________________________
____________________________
_________________________________________________________
____________________________
1520 Wakarusa Drive
Suite B
Lawrence, KS 66047
www.kawvalleyhearing.com
Patient History Form
(least important)
(most important)
1) How important is hearing the television better?
1
2
3
4
5
2) How important is hearing on the telephone?
1
2
3
4
5
3) How important is hearing in small groups at home?
1
2
3
4
5
4) How important is hearing better in church?
1
2
3
4
5
5) How important is hearing your children / grandchildren?
1
2
3
4
5
(Rarely)
(Often)
6) How often do you go to restaurants?
1
2
3
4
5
7) How often does your family complain about your hearing loss?
1
2
3
4
5
8) How often are you in a noisy environment?
1
2
3
4
5
9) How often does it sound as if people are mumbling?
1
2
3
4
5
(No)
(Sometimes)
(Often)
10) Does your hearing frustrate you?
1
3
5
11) Does your hearing frustrate your loved ones?
1
3
5
12) How long have you had trouble hearing?
1-2
3-5
6-8
8-10
10+
Years
Years
Years
Years
Years
13) How did you hear about us? ____________________________________________________________________
For Office Use Only
Survey Score: ________