Audiological History Intake Form Child - Syracuse Hearing Solutions

All hearing aids are different. It may be confusing to receive so many ads about many different hearing aids from many different hearing aid companies. There are so many different opinions on hearing aids that it makes it difficult to know what would be right for you. Are you concerned about investing in a hearing aid that may work for someone else, but may not work for you? Your hearing needs may be very different from someone else’s needs and we take that into consideration when helping you choose a hearing aid.

We carry most major manufacturers brands of hearing aids and have experience fitting over hundreds of different models of hearing aids.

Our Doctors of Audiology have the expertise to help you find the right hearing aid for you based on your hearing test results and your answers to the following questions…

Please attach your hearing test results and fill out the questionnaire so we can determine which hearing aid may be best for you.

Do you feel that you can hear but you can’t understand?

All the time Most of the time Some of the time None of the time

Do you feel that you rely on reading lips or seeing the speaker’s face in order to hear?

All the time Most of the time Some of the time None of the time

Are you sensitive to certain sounds?

Yes No Sometimes

Do certain sounds bother you?

Yes No Sometimes

Do certain voices bother you?

Yes No Sometimes

Which voices are most difficult to understand?

Male Female Child All of the above None of the above

Do you feel that you need to hear better..

All the time Most of the time Some of the time None of the time

Do family members and friends complain you can’t hear them?

All the time Most of the time Some of the time None of the time

Are you outdoors a lot?

Yes No Sometimes

Are you in loud surroundings?

All the time Most of the time Some of the time None of the time

Can you handle small batteries?

Yes No Sometimes

How would you consider your manual dexterity?

Excellent Good Fair Poor Unsure

Have you been told you have small ear canals in the past?

Yes No Unsure

Are you prone to sweating?

Yes No Sometimes

Do you feel you would have trouble putting a hearing aid on…

in your ear behind your ear both no trouble at all

Have you been told that you produce a lot of earwax?

Yes No Unsure

Do you consider yourself tech-savy?

Yes No Maybe Unsure

Do you have a smartphone?

Yes No Don't know what that is

Do you know about Bluetooth?

Yes No Somewhat Unsure

Would you be afraid of losing your hearing aids and want a way to track them with your phone?

Yes No Unsure

Would you like the ability to hear television, music, sound, directed wirelessly through your hearing aids?

Yes No Maybe Unsure

Do you feel that your lifestyle is..

Very active and attend varying social situations

Somewhat socially active, going out to social occasions sometimes

Mostly quiet lifestyle

Indoors and in quiet all of the time

What level of hearing aid technology are you most likely to consider?

I want the best of the best technology for me

I don’t feel I need the best, but I don’t want to be unhappy if I go for less

I would like to hear better, but I am on a strict budget

If you answered yes to one or more of the previous questions, you should have a complete hearing evaluation performed by our audiologist

Finish the form below and a specialist will be in touch to set up your appointment.

Confidential Patient Audiologic History - Child ( <18 years of age)

Do you feel your child has trouble hearing? Describe concern:

Birth or pregnancy complications?

Yes

If yes, please explain:

Passed newborn hearing screening?

Yes

Language development - any developmental delays?

Yes

If yes, please explain

Developmental milestones met at appropriate ages?

Yes

History of ear infections?

Yes

If yes, how many and when was your child's last ear infection?

PE tubes?

Yes

If yes, when were the tubes placed?

Family history of hearing loss?

Yes

Who?

Other medical history (other diagnoses?):

Academic performance (if applicable)

Describe academic performance:

Any areas of difficulty?

Does your child receive any support services? (SLP, PT, OT, Special education)

Please check all that apply. If checked, please explain.

Tinnitus (sounds in the ear)?

Yes

If yes, LEFT, RIGHT, or BOTH ears?

Ear Drainage?

Yes

If yes, LEFT, RIGHT, or BOTH ears and when did it start?

Ear Wax Buildup?

Yes

If yes, LEFT, RIGHT, or BOTH ears and when did it start?

Family History of Hearing loss?

Yes

If yes, who?

History of Noise Exposure?

Yes

If yes, please describe:

History of ear trauma?

Yes

If yes, please describe:

History of head trauma?

Yes

If yes, please describe: