case history form at doctor


When you visit the audiologist for the first time, office staff will have you fill out a case history form. This paperwork asks you a series of questions to help the hearing healthcare professional better understand your medical and hearing history and health. The practitioner wants a subjective account of the symptoms a patient is experiencing or has experienced so that he or she can use it in conjunction with a physical exam to make a diagnosis.

Here are some of the questions that you will likely find on the case history form as well as an explanation about why the audiologist or hearing health care professional needs this information. The questions are asked to identify the symptoms for each ear separately.

case history form at doctor1. Do you or have you experienced ear pain, fullness or blockage?

This question can help the hearing health care professional determine if you have an ongoing medical issue, such as a growth or infection in the ear canal or ear drum, which may cause temporary hearing loss or tinnitus. Sometimes these symptoms, combined with others, can indicate a certain disease.

2. Do you or have you experienced any ringing, whooshing, roaring or other sounds when a sound is not actually present?

If you say “yes,” to this question, it is likely that you are experiencing tinnitus, which is a very common symptom among people with hearing loss. There might be additional questions related to tinnitus to determine the frequency and type of sound. Your answers can help the audiologist or other health care provider determine if your tinnitus should be further investigated.

3. Have you ever had an ear infection or ear surgery?

Many people have had ear infections, but fewer people have needed ear surgery. But your answer to this question will help the practitioner understand what he sees when he looks inside your ears. People who have had several or severe ear infections, as well as those who have had some type of surgery, often have scarring on the eardrum and other inner ear structures.

4. Do you have hearing loss in your family?

Though it is not always the case, there are some genetic links to hearing loss. Some of the most common hereditary hearing losses include: 

  • Waardenburg syndrome
  • Branchiootorenal syndrome
  • Stickler syndrome
  • Usher syndrome
  • Pendred syndrome
  • Alport syndrome

5. What are your hobbies? What is you occupation?

The hearing health practitioner wants to know whether you have been in an environment with repeated exposure to damaging noise or ototoxic chemicals that might account for your hearing loss. For example, if you ride motorcycles or go shooting and do not wear ear plugs or other protection, this can clue the audiologist into what might be going on.

6. Have you experienced dizziness or loss of balance? What is/was that like?

Our ears play a role in balance. If you are experiencing dizziness or imbalance, these symptoms in conjunction with others might point to a specific disease. You can likely expect several questions related to balance on a case history form.

7. What medications are you currently taking?

Some medications have side effects including tinnitus or dizziness. It’s more likely that these adverse symptoms will happen when individuals are using a combination of medications. Other medications are ototoxic, meaning they are damaging to the ears and can cause hearing loss. Let your audiologist know what medications and supplements you are taking so he can rule this out as a cause of your hearing loss.

8. Questions on general health status

Hearing loss can be a side effect or symptom of various health conditions. For example, with heart disease, blood flow to the ear may be restricted, resulting in hearing loss. But it’s also important for your audiologist to know if you have feelings of depression or loneliness, which may be caused by your hearing loss.


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