Case History: Adult Hearing Evaluation 1. Please tell us about your hearing concerns. 2. My hearing is __________________. a. better in the right ear b. better in the left ear c. about the same in both ears 3. Do you have difficulty hearing _________________? a. in noisy places YES NO d. the television YES NO b. in quiet places YES NO e. over the telephone YES NO c. in restaurants YES NO f. the direction of sounds YES NO 4. Do you have a history of __________________? ear infections YES NO ear pain YES NO allergies YES NO headaches YES NO fluctuation in hearing YES NO ear surgery YES NO dizziness YES NO noise exposure YES NO fullness in ears YES NO ringing or roaring YES NO hearing loss in family YES NO 5. Have you had ________________? meningitis YES NO diabetes YES NO measles YES NO kidney disease YES NO scarlet fever YES NO seizures YES NO tuberculosis YES NO multiple sclerosis YES NO syphilis YES NO concussion YES NO head fracture YES NO chemotherapy YES NO Are you currently taking any medication? YES NO If so, please list: _________________________________________________ 6. Have you previously worn hearing aids? YES NO 7. Please use the space below to give us additional information you feel would be helpful to the person testing your hearing.