Hearing Analysis Questionnaire

Name     Email Address

Address   City State

Phone      Date of Birth

Additional Info

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 hearing loss?

3. Which ear do you think is better?  left right

4. Any history of  or active drainage from the ear within the previous 90 days?  yes no

5. Any history of sudden or rapidly progressive hearing loss within the last 90 days? yes no

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 no

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 no

If yes, Physician who treated you:

                               Street Address

                               City /State/ Zip

                                            Phone 

11. Are there other members of your family who have a hearing problem? yes no

Assessment of communication  problems:

1. Do you hear people speaking, but have difficulty in understanding the words? yes no

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 no

4. Do you have difficulty understanding in a small groups? yes no

5. Do you have difficulty understanding on the telephone? yes no

Which ear do you use on the telephone? left right

6. Can you hear the phone ring? yes no

7. Any problems when listening to a sermon in church or a lecture in a large hall? yes no

8. Do you have to turn the radio or television up louder than normal? yes no

9. Must others ever raise their voices or come closer to make you hear them? yes no

10. Have you ever decided to avoid a social situation you enjoy because of your

hearing problem? yes no

11. Do you ever have to concentrate so much to listen that you become tired or

fatigued from it? yes no

12. Can you hear car horns, sirens, or other warning signals when they occur? yes no

amplification history:

1. Have you ever used a hearing aid? yes no

If Yes, Type and Brand ?

When Purchased? Which Ear Fitted?   left right both

2. Description of performance of present/past instrument:

Have Dr. Luckett give me a call to discuss my personal hearing solutions.

Please ...no one call, but send informational brochures.

Have office call to schedule a no obligation, Complimentary Preliminary Consultation.

Thank You!