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





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.