Audiology Case History Form
Complete this form to share your audiology history, current hearing concerns, and related symptoms so the visit can be prepared appropriately.
Patient and Contact Details
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Audiology History
Primary reason for visit
*
Do you currently have hearing concerns?
*
Yes
No
Unsure
Which ear(s) are affected?
Left
Right
Both
Unsure
Prior hearing-related care
None
Hearing test only
Hearing aid use
Ear specialist visit
Other
Current Symptoms and Concerns
How long have you been noticing these symptoms?
*
Describe your main concern or symptom in your own words
*
Associated symptoms or concerns
Ringing in the ears (tinnitus)
Dizziness or imbalance
Difficulty hearing in noise
Ear fullness or pressure
Sound sensitivity
Other
Submit
Should be Empty: