This form is to be completed along with the adult hearing health history form. Please submit both forms prior to your appointment.

To download a PDF of this form, please CLICK HERE!

    Personal Information





    TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther



    YesNo

    YesNo



    nausearinging or noises in your ear(s)hearing lossvisual disturbancesOther


    YesNo


    YesNo


    RightLeftBackFrontNo Pattern

    YesNo

    YesNo



    YesNo


    GradualSuddenOther


    YesNo


    YesNo

    YesNo

    Rolling your body right or leftTurning your head left or rightLooking up, or head back positionBending over, or head down positionGoing from lying to sitting positionOther


    YesNo

    Not moving your headRestMedicationOther



    YesNo

    Moving your headRiding or driving in the carLarge crowds or busy walkwaysWhen you’re hungry or haven’t eatenOther


    BetterWorseSame

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Right earLeft earBoth ears

    YesNo

    Have you experienced any of the following (Indicate if constant or episodic):


    YesNo

    ConstantEpisodic


    YesNo

    ConstantEpisodic


    YesNo

    ConstantEpisodic


    YesNo

    ConstantEpisodic


    YesNo

    ConstantEpisodic


    YesNo

    ConstantEpisodic


    YesNo

    Primary MDEar, Nose, Throat MD (ENT)NeurologistAudiologistCardiologistEmergency Room MDPhysical Therapist

    Have you had tests done for this problem elsewhere?


    YesNo




    YesNo




    YesNo






    Please arrive 15 minutes prior to your scheduled appointment time.