This is a copy of the VA Medical Center Audiology Questionaire. To be treated, you have to fill this out. If anyone needs a copy of this, just 'Shift-click' on the link to open the document yourself.
Google Docs - Audiology Questionaire blankTo use the code in the form, just remove this paragraph. There are three pages of questions.
CINCINNATI VA MEDICAL CENTER
AUDIOLOGY SECTION
CASE HISTORY FORM
Please complete the following and return it the day of your appointment so that we may best be able to serve your needs.
Name: _ __________________________ Date:
SSN: ___________________________________ DOB:
A. Purpose of Referral
What is your primary reason for being seen in Audiology?
B. Hearing Loss
Do you have difficulty hearing?
Which ear?
Which ear is poorer?
When did it start?
Did it happen suddenly of gradually?
What do you think is the cause of your hearing loss?
What situations do you have the most difficulty hearing?
Do you have a family history of hearing loss before age 50?
C. Noise History
Military noise history (Include branch of service and dates of active duty):
Were you in active combat? (if so, please describe):
Occupational noise history (type of employment and years exposed to noise):
Recreational noise history:
Were hearing protection devices worn?
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Ringing in the Ears (Tinnitus)
Do you have ringing or other noises in your ears or head?
What does it sound like?
Ringing Buzzing
Pulsing Roaring
Crickets Other (Please describe)
Right, left, both ears, or in the head?
In which ear is worse is the tinnitus worse?
When did your tinnitus start?
How often do you hear it?
What do you think is the cause of your tinnitus?
How annoying is your Not annoying Very annoying
Tinnitus? 0 1 2 3 4 5
E. Dizziness
Do you have dizziness or balance problems?
Under what conditions? (example, with a change in body of head position, or does it
occur spontaneously?
How often does it occur?
When did it begin?
What does it feel like? Lightheadedness Spinning
Feeling of Falling Unsteadiness
Other (Please describe)
What do you think is the cause of your dizziness?
F. Ear Symptoms
Do you have any of the following? If so, please indicate which ear or both
Ear Pain? Yes No Right left Both
Drainage? Yes No Right left Both
Fullness/pressure? Yes No Right left Both
Have you had any of these symptoms before (please explain)
Have you ever had ear surgery?
Date Ear facility Type/Reason
G. Medical History
What other health problems do you have?
Have you ever had a stroke?
Have you ever been treated for any of the following (check all that apply):
Prolonged infection Tuberculosis
Malaria Cancer
Pneumonia
H. Hearing Aid History
Have you ever worn a hearing aid?
If so, what type of hearing aid was it (for example, behind-the-ear, in-the-ear, in-the-canal):
What is the condition of the hearing aid(s) now?
Additional comments about hearing aid use (degree of satisfaction, situations presenting
problems, etc.):
If you do not already use hearing aids, do you feel you need them?
