Audiological History Intake Form - 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.

Auditory Processing Case History Form

Today's Date

Date of Birth

Address

City

State

Zip Code

Home Phone

Cell Phone

Please note that not all insurances will cover the cost of this testing. Please contact your insurance company for more information regarding coverage. We will bill your insurance for testing; however, you will be responsible for your copay and any applicable non-covered portion.

Referred by:

Person Completing Form:

Relationship to Patient

Parent/Guardian

Self

Other

Results will be sent to names/locations listed below if address or fax number is provided.

Name

Address or Fax

Phone

I authorize Preferred Audiology Care, LLC to disclose the results of this evaluation to those listed above:

Signature

Relationship to Patient

Parent/Guardian

Self

Printed Name

Results will not be available on the day of the evaluation as all results must be analyzed. A report will be ready by 10-14 days after testing is complete. The report will explain the findings and recommendations for school and home. Parents may contact the audiologist who completed the evaluation if they have any questions about the results.

Reason(s) for testing

Medical History

Do you have a history of ear infections?

Yes

If yes, how many and when was the last ear infection?

Have you ever had PE tubes?

Yes

If yes, when?

Do you have a documented hearing loss?

Yes

If yes, please describe:

Family history of hearing loss?

Yes

Family history of APD?

Yes

Family history of learning disabilities?

Yes

Have you ever had a concussion or TBI?

Yes

Do you have a chronic illness or disease?

Yes

If yes, please explain:

Please list all medications you are currently taking:

Please note any other pertinent medical information:

Have you ever been evaluated for APD before?

Yes

If yes, where?

Describe results:

Have you ever been diagnosed with any of the following?

Learning disability?

Yes

Mental delays?

Yes

Speech/Language Disorder?

Yes

ADD or AD/HD?

Yes

If yes, is medication prescribed and is it being taken?

Results of medication?

Physician managing care:

Other diagnosis?

Yes

If you answered yes to any of the above, please describe:

*If you answered yes to any of the above, please include copies of professional evaluations/reports.

Educational/Occupational Information:

Are you (check one):

Right handed

Left handed

Mixed dominant

Occupation:

Highest level of education:

Did you have an IEP in school?

Yes

If so, what educational supports did you have?

Do you notice concerns with any of the following?

Please check Yes or No for the following:

Trouble understanding TV?

Yes

Sensitivity to loud sounds?

Yes

Trouble telling where sounds are?

Yes

Problems following direction?

Yes

Difficulty with phonics?

Yes

Difficulty with spelling?

Yes

Difficulty pronouncing words/sounds?

Yes

Easily distracted?

Yes

Daydreams?

Yes

Forgetful?

Yes

Social difficulties?

Yes

Disruptive?

Yes

Preference for solitary activity?

Yes

Lacks motivation?

Yes

Easily frustrated?

Yes

Tires easily?

Yes

Often tense or anxious?

Yes

Uncooperative?

Yes

Clumsy?

Yes

Impulsive?

Yes

Lacks self-confidence?

Yes

Easily upset by new situations?

Yes

Has a problem with time concept?

Yes

Underachiever?

Yes

Involved with drugs?

Yes

Confused in noisy places?

Yes

Often says “huh” or “what”?

Yes

Mixes up sounds?

Yes

Difficulty with reading mechanics?

Yes

Difficulty with reading comprehension?

Yes

Small vocabulary compared to peers?

Yes

Does not complete assignments?

Yes

Restless?

Yes

Problem sitting still?

Yes

Rowdiness?

Yes

Needs quiet to study?

Yes

Headaches?

Yes

Short attention span?

Yes

Temper tantrums?

Yes

Easily frustrated or confused?

Yes

Hyperactive?

Yes

Disobedient?

Yes

Shy?

Yes

Irritable?

Yes

Destructive?

Yes

Seeks attention?

Yes

Occupational Concerns: