Hearing and Balance Questionnaire

Step 1 of 2

50%

Patient Name*
Date of Birth*
MM slash DD slash YYYY
Date*
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
I have reviewed all information in the health survey and discussed it with the patient/guardian.
Audiologist Signature
Date
MM slash DD slash YYYY
By submitting this form I agree to the Terms of Use
Comments
This field is for validation purposes and should be left unchanged.

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Step 1 of 2

Chief Complaints:

History of Present Illness:

Hearing History:

Dizziness History (complete if patient has dizziness):

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