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Cromwell

Contact Us

Home
About Us
Our Staff

Hearing FAQs
Services
Hearing Evaluations And Testing

Hearing Aid Fitting And Repair

Custom Ear Molds And Ear Plugs

Tinnitus Evaluation
Hearing Health
What To Expect At Your First Visit

Types Of Hearing Loss

Types Of Hearing Aids

Smart Hearing Aids

Caring For Your Hearing Aids

Hearing Aids We Carry

Patient Forms

Otc Hearing Aids

Hearing Loss and Brain Health
Blog
Review Us
Cromwell
Contact Us

Phone Number (860) 632-5003

Location Cromwell, CT 06416

Patient History Form

Patient Name

Date

Email

Chief Complaint:
Hearing Loss

Tinnitus/Ringing

Dizziness

Difficulty hearing

Telephone ( Right ear Left ear)
How long have you noticed this difficulty?
Is this problem due to a work-related injury/exposure?
Yes

No
Do you feel your hearing is changing?
Yes

No
Have you ever been exposed to loud noise. either recently or in the past?
Yes

No
Have you seen an Ear,Nose and Throat Physician?
Yes

No
Have you ever had surgery that may have affected your hearing?
Yes

No
Is there a history of hearing loss in your family?
Yes

No
Have you ever had an ear infection?
Yes

No
Have you, in the past 10 years, experienced chronic or acute dizziness, lightheadedness, or vertigo?
Yes

No
Do you take any prescription medications on a regular basis? Please list:
Medication:

For:

Medication:

For:

Medication:

For:
Please check any of the following that you currently have or have had in the past:
Arthritis

HIV

Malaria

Asthma

Head Injury

Measles

Parkinson's

Bell's Palsy

Heart Trouble

Meningitis

Sinusitis

Cancer

Hepatitis

Mumps

Stroke/TIA

Diabetes

High Blood Pressure

Neurological Symptoms

Visual Trouble-Loss/Sight
Please rank the following in order of importance (1-4). if a hearing aid is recommended for you:
Improved hearing in quiet

Improved hearing in noise

Cosmetic appearance

Expense
If you are currently using a hearing aid, or have in the past, please answer the following:
Which ear is/was aided?
Right

Left

Both

None

How long you have used a hearing aid?

What would improve your current hearing aid?

Improve your life through better hearing.

160 West Street Bldg 1, Suite B Cromwell, CT 06416

Office Hours :

Monday, Tuesday, Thursday and Friday 09:00AM – 04:30PM. CLOSED on Wednesdays.

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