SaferHearingNow.com
SaferHearingNow.com
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Hearing Health Case History Form
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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
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
How often are you exposed to loud noise?
Daily
Weekly
Occasionally
Rarely
Never
What are the primary sources of noise exposure?
Work (e.g., factory, military)
Music (live or headphones)
Power tools/machinery
Hunting/shooting
Recreational vehicles
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
Leave this field empty
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