Hearing Health Case History Form | SaferHearingNow.com

Name *

Age *

Younger than 18 years
Between 18 -25 years
Between 26 - 45 years
Between 46 years -60 years
Older than 60 years

Email address *

Job/Occupation

How often are you exposed to loud noise?

Daily
Weekly
Occasionally
Rarely
Never

Do you have a history of hearing loss?

Yes
No
Not sure

Have you had a hearing test before?

Yes
No

Have you noticed any of the following recently? (Check all that apply)ew field

Trouble hearing in noise
Ringing (tinnitus)
Sounds seem muffled
Ear pain
Dizziness or imbalance
Feeling of fullness in ear
Sudden hearing loss

Which ear is affected?

Right
Left
Both
Not sure

Have you worked or lived in a noisy environment?

Yes
No

What are the primary sources of your noise exposure?

Work (e.g., factory, military)
Music (live or headphones)
Power tools/machinery
Hunting/shooting
Recreational vehicles
Other

Do your have a hearing aid?

Yes
No

If you have a hearing aid, where did you acquire it? *

Purchased as a prescription aid from an audiologist
Purchased as an over-the-counter (OTC) hearing aid.
Passed down from a relative or friend.
From the Veterans Affairs (VA)
Other

Do you use hearing protection (earplugs, earmuffs)?

Yes
Sometimes
No

Have you had any of the following?

Ear infections
Ear surgery
Head trauma
Allergies
Diabetes
High blood pressure
Chemotherapy or ototoxic medication
None of the above

Are you currently taking any medications?

Yes
No

Do you have access to the following?

Smartphone Internet connection
Email account
Digital otoscope
None of the above.

Have you used any of the following apps before?

Hearing test apps (e.g., Mimi, HearWHO)
Sound level meters (e.g., Decibel X, NIOSH SLM)
Otoscope viewer apps
None of the above

What are your goals for this program? (Check all that apply) *

Monitor my hearing over time
Reduce my noise exposure
Get professional feedback (remotely)
Get referred for in-person care if needed
Learn about hearing protection
Uncertain

Have you been classified as being deaf?

Yes
No
Not sure

Are you now or have you received any vocational rehabilitation services?

Yes
No

What is your best means of communication?

Speaking and hearing
Sign language
Writing
Other

Which of the following do you routinely use (check all that apply)

Cochlear implant
Conventional hearing aid(s)
Sign language interpreting services
Real-time captioning
Assistive listening devices
Speech-to-text technology
Other_____

Which of the following do you feel you need? (check all that apply)

College
Career exploration for high school students who are Deaf/HOH
Work-based learning experiences
Help with transition from school-to-work
Counseling for workplace adjustment(s)
Peer mentoring with other Deaf professionals (e.g., attorneys, physicians, businesspersons, etc.).
Other

Do you need help with: (select all that apply)

Finding job openings that match skill and interests
Employer education about Deaf culture and communication strategies
Arranging for workplace accommodations under the ADA
Job coaching to ease the transition into new roles
Hearing aids or cochlear implant accessories
Visual alerting systems
Videophones or video relay services
Captioned telephone services or IP relay
Other

Send me a copy