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Hearing and Balance Questionnaire

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Phone

This field is for validation purposes and should be left unchanged.

Patient Name*

Date of Birth*

Date*

Sex*

M

F

Referring/Family Doctor

Tel #*

Email*

Chief Complaints:

Please check all reasons below that have brought you to Becker, Nose & Throat:*

Hearing Loss

Dizziness

Ringing/Sounds in Ears

Other

Untitled*

History of Present Illness:

How long have you had this/these problem(s) and when did they start?*

Rate your problem’s severity on a scale of 1 to 10*

What type of treatments/medications have you received for your problem(s)? Have they helped?*

Hearing History:

Duration of loss?

Sudden or Gradual Onset?*

Sudden

Gradual

Which ear?*

Right

Left

Both

Which ear is used for phone calls?*

Right

Left

Both

Tinnitus or noises in ears/head?*

Yes

No

If yes, describe*

Noise or music exposure (military, work, hobby)?*

Yes

No

If yes, describe*

Family History of hearing loss?*

Yes

No

Ear infections/ear surgery?*

Yes

No

Ear pain/drainage?*

Yes

No

Ear wax problems?*

Yes

No

Dizziness History (complete if patient has dizziness):

When did dizziness begin?

Constant or Occasional?

Constant

Occasional

Which term best describes your dizziness?

Spinning

Lightheadedness

Imbalance

Duration each episode?

Seconds

Minutes

Hours

Days

Dizziness worse at a particular time of day?*

Yes

No

If yes, describe*

Does something in particular bring on the dizziness?*

Yes

No

If yes, describe*

Can you or anything cause to dizziness the stop/decrease?*

Yes

No

If yes, describe*

Family history of dizziness?*

Yes

No

If yes, describe*

Head trauma in the past?*

Yes

No

If yes, describe*

Do you get migraines?*

Yes

No

If yes, for how many years?*

Do you have motion sensitivity (car, boat, amusement rides)?*

Do you take medications that could contribute to your dizziness?*

Yes

No

If yes, describe*

Tinnitus (ear noises) History (complete if patient has tinnitus):

Do you have noises in your ears?*

Yes

No

Which ear is affected?*

Right

Left

Both

When did tinnitus begin?

Can you describe it?

Does anything mask (or cover up) the tinnitus?*

Yes

No

If yes, describe*

Is the noise louder at a particular time of day?*

Yes

No

When

Does the noise change pitch or loudness or both?*

Yes

No

If yes, describe

Does the tinnitus interfere with daily activities?*

Yes

No

If yes, describe*

Does the tinnitus interfere with sleep? Rate annoyance of tinnitus (1 to 10, 1=minimally annoying, 10=excessively annoying)*

Patient/Guardian Signature*

Date*

I have reviewed all information in the health survey and discussed it with the patient/guardian.

Audiologist Signature

Date

By submitting this form I agree to the Terms of Use

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Call one of our locations now!

Freehold, NJ: (732) 375-9550
Hillsborough, NJ: (908) 271-2102
Lawrenceville, NJ: (609) 303-5163
Monroe, NJ: (609) 831-0779
Mt. Laurel, NJ: (856) 724-4031
Mullica Hill, NJ: (856) 478-3111
Philadelphia, PA: (215) 671-6330
Philadelphia, PA: (215) 929-8301
Plainsboro, NJ: (609) 681-6939
Princeton, NJ: (609) 759-8500
Princeton, NJ: (609) 430-9200
Robbinsville, NJ: (609) 436-5740
Sewell, NJ: (856) 589-6673
Voorhees, NJ: (856) 772-1617
Voorhees, NJ: (856) 565-2900
Yardley, PA: (267) 399-4004
Woodbury, NJ: (856) 845-8300

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