Quinte Hearing Centre
Patient Information Form
Patient Name
Physician / Referral
Date
Hearing History
Last hearing exam:
Primary concern:
When did you notice this:
Onset:
Preferred ear:
Hearing Aids
Currently wearing aids?
Details:
Tinnitus
Do you have tinnitus?
Details:
Dizziness / Vertigo
Do you have dizziness or vertigo?
Details:
Ear Symptoms
| Symptom | Side |
|---|---|
| Pressure / Fullness / Pain | |
| Hyperacusis / Sound sensitivity | |
| Chronic ear infections |
Medical History
Check all that apply:
Noise Exposure
History of noise exposure?
Details:
Surgery
Surgery of the head or neck?
Details:
Family History of Hearing Loss
Family history of hearing loss?
Details:
Accident / Head Injury
History of accident or head injury?
Details:
Notes
