Advanced Audiology Associates | Patient History Form

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Yarmouth Port: 508-385-5222

Marstons Mills: 508-539-9780

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Confidential Patient History

I prefer my appointments are confirmed by: *

Email

Text

MEDICAL HISTORY

Have you seen a doctor in the past 6 months? *

Yes

No

Have you seen a doctor specializing in diseases of the ear in the last 5 years? *

Yes

No

Have you ever had your hearing tested? *

Yes

No

Have you ever had any type of ear surgery? *

Yes

No

Do you take medicine every day? *

Yes

No

Do you have any other medical conditions? *

Yes

No

ABOUT YOUR EARS

Do you have any of these symptoms?

Drainage from the ear *

Yes

No

Sudden or rapid hearing loss in the past 90 days *

Yes

No

Acute or chronic dizziness/vertigo *

Yes

No

Ringing or buzzing (tinnitus) in either ear *

Yes

No

If yes, which ear?

Right

Left

Same in both ears

Which is your poorer ear? *

Right

Left

Same

Have you ever seen a doctor for wax removal? *

Yes

No

Do you have a history of noise exposure (industrial, military or recreational)? *

Yes

No

ABOUT YOUR HEARING

Do you experience difficulty with the following?

Understanding conversation *

Yes

No

Hearing in a crowd *

Yes

No

Hearing on the telephone *

Yes

No

Which ear do you use on the phone? *

Right

Left

Either

Hearing or understanding the television *

Yes

No

Does anyone else in your family have a hearing problem? *

Yes

No

Do you now or have you ever worn a hearing aid? *

Yes

No

Are you ready for help if a hearing loss is discovered? *

Yes

No

By checking this box, I agree to have this information sent to Advanced Audiology Associates, Inc.

Yarmouth Port Office

714 Main Street (Rt. 6A)

Yarmouth Port, MA 02675

508-385-5222

Marstons Mills Office

86 Cotuit Rd. (Rt 149), Unit B1

Marstons Mills, MA

508-539-9780

Advanced Audiology Associates, Inc. is a full-service hearing care practice. We can provide physician-ordered diagnostic hearing testing, hearing aid evaluations and consultations, advanced hearing aid technology, hearing aid accessories, batteries, and assistive listening devices.

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