Hearing Analysis Questionnaire
Date of Birth
History of Hearing Impairment:
1. Have you had a previous hearing
evaluation? yes no
If yes, when was your last one?
2. What do you think caused your
3. Which ear do you think is better?
4. Any history of or active
drainage from the ear within the previous 90 days? yes
5. Any history of sudden or rapidly
progressive hearing loss within the last 90 days? yes
6. Have you experienced any acute or
chronic dizziness? yes no
7. Is there any unilateral hearing
loss of sudden or recent onset within the last 90 days? yes
8. Have you experienced any pain or
discomfort in the ear? yes no
9. Do you have any noises or ringing
in your ears? yes no
If yes , describe
10. Have you received any medical or
surgical treatment for your hearing loss? yes
If yes, Physician who treated you:
City /State/ Zip
11. Are there other members of your
family who have a hearing problem? yes
Assessment of communication problems:
1. Do you hear people speaking, but
have difficulty in understanding the words? yes
2. Do you hear some people better
than others? yes no
If yes, Describe
3. Do you have difficulty
understanding in a large crowd? yes
4. Do you have difficulty
understanding in a small groups? yes
5. Do you have difficulty
understanding on the telephone? yes
Which ear do you use on the
telephone? left right
6. Can you hear the phone ring? yes
7. Any problems when listening to a
sermon in church or a lecture in a large hall? yes
8. Do you have to turn the radio or
television up louder than normal? yes
9. Must others ever raise their
voices or come closer to make you hear them? yes
10. Have you ever decided to avoid a
social situation you enjoy because of your
hearing problem? yes
11. Do you ever have to concentrate
so much to listen that you become tired or
fatigued from it? yes
12. Can you hear car horns, sirens,
or other warning signals when they occur? yes
1. Have you ever used a hearing aid?
If Yes, Type and Brand ?
Which Ear Fitted? left
2. Description of performance of
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Complimentary Preliminary Consultation.
Copyright © 2006 by Speaking of Hearing/Joseph C.
Luckett/Deseabel Hearing Inc.. All rights reserved.