Musician’s Confidential Case History Form

Name:

Date of Birth: SSN:

Address:

Phone: HM- WK: FAX: EMAIL:

Ear Health History

Describe any medical problems you have had with the health of your ears:

Check all that apply and describe details in comment section:

Ear Infections	Ear drainage	Perforated eardrum	Ear Surgery
Other Medical Conditions	Ear surgery	Other:

Comments:

List family members who have experienced hearing loss, the age they acquired their hearing loss, how they are related to you, and what you believed caused their hearing loss?

Do you have any of the following? Check all that apply and describe in comment section:

Headaches

Tinnitus/ Ringing in ears

Dizziness

Difference between ears? If so, which ear is better?

Do your ears ring or feel stuffed up after a performance? Rehearsal? Concert?

If you have Tinnitus (ringing in the ears) is it in one ear (L or Rt), or both ears?

Is the tinnitus constant or periodic?

What factors make the tinnitus worse?

Are you super sensitive to loud sound?

General Health History Physician’s Name:

Describe any major medical problems you have had:

List the medications you are currently taking, or any that you have taken in the past that you feel may have affected your hearing.

List any allergies including, medications, foods, or environmental irritants:

Check all that apply and describe details in comment section:

Head Injury	Scarlet Fever	Mumps, Measles	Tuberculosis
Diabetes	Seizures	Syphilis	HIV+
Dialysis	Heart Problems

Performance History:

Name of Band (s): Do you sing with your group? Yes/No

Performance History:

Name of Instrument

Years Played

Hours per Day Played

Do you wear headphones?

Mark your position on stage in relation to other performers:

Stage Right

Stage Left

Occupational Hearing History

Circle all that apply and indicate (+/-) whether or not hearing protection devices used:

Military service	Noise exposure at work	Recreational noise exposure, e.g. motorcycle	Hobbies that make loud noise
Guns, Target shooting	Farm equipment	Power tools	Engine noise

I authorize the release of any medical or other information necessary to process this claim. I also request payment of benefits to Veronica H. Heide, Au.D., Audible Difference LLC.

Signature Date