QUESTION

YES

NO

Do you have hearing loss?

1. If yes, when did it begin? _____________________

Right ear only?

Left ear only?

Both ears?

If both ears, which is worse?   LEFT     or     RIGHT

Do you have fullness or pressure in your ears?

Does your hearing fluctuate? (go up or down)

A.     Which ear?   LEFT     or    RIGHT      or     BOTH

Do you have Tinnitus? (noise in ears)

1. Which ear?   LEFT     or     RIGHT     or     BOTH
2. Describe the noise__________________________
3. Is it?    Constant     or     Intermittent

Does your ear ever drain?

1. Is there an ODOR ___________COLOR_________?

Recurrent ear infections?

1. How many infections in the past year? ____________
2. How were they treated? ________________________
3. Who treated past infections? ____________________

Have you ever had surgery on your ears?

1. If yes, what kind? ____________________________

Is there a family history of hearing loss?

1. Who in your family? __________________________

Do you wear hearing aids?

1. Which ear?     LEFT EAR     or     RGHT EAR     or     BOTH

Do you have dizziness?

Do you have any additional information regarding your hearing loss?

________________________________________________________

________________________________________________________

________________________________________________________