An audiology case history form with room for both ears and every device

Two ears, several devices, and a fixed grid that cannot hold them

Audiology case history is unusually repetitive in structure, and standard forms handle it badly. Hearing changes differ between ears. A patient may have had three sets of hearing aids over fifteen years. Noise exposure is rarely one job. Ear surgery may have happened twice, decades apart. A case history form audiology practices inherit typically offers one line each and forces everything else into the margin. This preset repeats those sections instead, and carries adult and paediatric modes in one document. It is editable throughout, the PDF is available immediately, and there is no signup or email wall.

• Built for HIPAA-compliant workflows

• Free to start — 50 patient actions each month

What an audiology case history form usually covers

The reason for the visit and who suggested it. Hearing difficulty described per ear — when it started, whether gradual or sudden, and whether it is changing — since sudden change on one side matters and a single combined question hides it. Tinnitus, dizziness or balance problems, and ear pain or discharge, each with side and duration. Ear history: infections, surgery, perforations and trauma, recorded as repeating entries with rough dates. Noise exposure across occupational, military and recreational sources, one row each, with hearing protection used. Family history of hearing loss. Relevant medical history and medications, including anything the patient has been told may affect hearing. Previous hearing tests and where they were done. Devices already tried, one row each with dates and how the patient got on. In paediatric mode the guardian completes it, and the form adds birth and early history, ear infection frequency, speech and language development, school listening environment and any support in place.

The questions that reveal what a test cannot

Two questions earn their place beyond the clinical history, and both are about the person rather than the ear. The first asks in which specific situations hearing is hardest — a restaurant, a meeting, the television, one grandchild's voice — because that list becomes the goal, shapes counselling and predicts device satisfaction better than almost anything else. The second asks who else has noticed and how it affects them, since a spouse or a teacher is frequently the reason the appointment was made at all and their account often differs usefully from the patient's. Both are open fields written in the patient's own words. Neither is a scored questionnaire, and that is deliberate.

Edit it in plain language, download exactly what you built

Rename the form, rewrite any question or helper text, mark fields required or optional, switch between adult and paediatric modes, adjust how many repeating rows appear, and add, duplicate, reorder or remove sections. A practice fitting mostly hearing aids for older adults and one doing mostly paediatric diagnostics need different things from the same starting point. A default PDF is ready as soon as the page loads, and after any change a new PDF is generated from your current version, so what downloads is what you built. It prints on US Letter with clean page breaks and reset restores the original preset.

A two-audiologist practice, half an hour

A practice fitting hearing aids for mostly older adults starts from this preset. They expand the previous-devices rows to four, having found that patients arriving with a drawer of old aids were the norm rather than the exception. They make the per-ear onset questions required, after a sudden unilateral change was nearly missed on a combined question. They add the listening-situations question at the front, because the lead audiologist uses it in counselling at the fitting appointment weeks later. They leave the standardised handicap questionnaire a colleague suggested out of the intake entirely, keeping it in the clinical workflow where it is administered properly. Half an hour, and appointments start with a goal already written down.

History here, measurement in the booth

Everything on this form is reported by the patient or their guardian and recorded exactly as given. It holds no audiometric thresholds or test values, contains no standardised symptom or handicap instrument and reproduces none — those have their own administration and scoring rules and belong in your clinical workflow rather than on an intake page. It produces no score, flags nothing as a red flag requiring urgent review, suggests no diagnosis, prescribes no hearing aid and recommends no treatment. All of that is the work of a licensed audiologist with the patient in the booth. This is an original document rather than a copy of any published or association form. Have a licensed audiologist review the history questions for your caseload, and your attorney review consent and, for paediatric use, guardian wording, which varies by state. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, and as this is a public builder, build the blank form here rather than entering real patient details.