Hearing Aid History Form
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1HEARING AID HISTORY
Name: ________________________________________________________ Date: __________________________
Please read the following list. Check the appropriate areas in which you
feel your current hearing aids need improvement.
______
Visibility
______
Background Noise
______
Feeling Stopped Up
______
Wind Noise
______
Feedback (Squealing)
______
Understanding in Noise
______
Understanding in Quiet
______
Soft Sounds Too Soft
______
Telephone Use
______
Loud Sounds Too Loud
Hearing Aid Information:
Age of Hearing Aid
__________
Where Purchased
__________________
Office Use Only:
RIGHT
LEFT
Brand
__________________
Brand
__________________
Model
__________________
Model
__________________
SN
__________________
SN
__________________
Battery Size
__________________
Battery Size
__________________
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Parent category: Medical