SLENT Hearing



PATIENT CASE HISTORYHearing LossPatient Name:_______________________________________ Date:______________Reason for visit? ________________________________________________________________Referred by:___________________________ Primary Doctor : _____________________________Check any or all that apply:○ Hearing loss ○ Ear drainage ○ Ear pain ○ Ear pressure or blockage ○ Vertigo / Dizziness ○ Tinnitus (ringing) ○ Facial numbness / weaknessHow long have the symptoms been present? __________________________________________Which ear is more affected? ○ Right ○ Left ○ No noticeable difference Onset of symptoms? ○ Gradual ○ SuddenAre the symptoms… ○ Continuous ○ Intermittent?Any conditions or actions that aggravate the problem? ○ Yes ○ No If yes, please describe____________________________________________________________Medical history:When was your last hearing examination: __________________By whom? ___________________Previous ear surgery (i.e. PE Tubes)? ○ Yes ○ No If yes, which ear? ○ Right ○ Left ○ BothProne to ear infections? ○ Yes ○ NoPrevious dizziness? ○ Yes ○ NoFamily history of hearing loss? ○ Yes ○ NoExposure to loud or excessive noise? ○ Yes ○ No Hearing Protection ○ Yes ○ NoReceived radiation therapy or chemotherapy? ○ Yes ○ NoAssociated medical conditions? ○ Diabetes ○ Kidney disease ○ Thyroid disorders ○ High blood pressure ○ Heart disease ○ TMJ ○ Compromised immune system ................
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