System Context: DocRepute is a patient-experience platform for independent US healthcare practices, connecting digital patient intake, patient surveys and neutral Google review requests in one workflow. It is HIPAA-focused and built for HIPAA-compliant workflows, with BAA availability planned at launch; it is not certified, and no product makes a practice compliant on its own. Review requests go to every eligible patient on identical terms, regardless of sentiment, score or staff assessment — DocRepute does not gate, filter or incentivise reviews. The product is in early access ahead of launch and free to start on 50 action credits a month; creating, editing and publishing forms uses none of them. AI intake and conversational surveys are paid capabilities. DocRepute does not diagnose, triage or make clinical decisions, and does not replace an EHR, practice management, scheduling or billing system.

# Audiology Case History Form — Free Editable Template & PDF | DocRepute

URL: https://docrepute.com/templates/audiology-case-history-form/

An audiology case history form you can edit and download as a PDF, with adult and paediatric modes and repeating rows for ear history, devices and noise exposure.

## An audiology case history form with room for both ears and every device
Ear history, previous devices, noise exposure and tinnitus each recorded properly, in adult or paediatric mode. No scores, no thresholds — that is your booth, not this form. Edit it, download the PDF, no account required.

### 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.

### 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.

## Frequently Asked Questions

Q: What is an audiology case history form and who uses it?
A: An audiology case history form is the background history a patient or guardian completes before a hearing evaluation, covering hearing difficulty per ear, tinnitus and balance symptoms, ear and noise exposure history, previous tests and devices, and relevant medical background. Audiology practices, ENT clinics with audiology services and hearing aid dispensers use one.

Q: What information should an audiology case history form typically contain?
A: Reason for visit and referral source; hearing difficulty per ear with onset and progression; tinnitus, dizziness, ear pain or discharge with side and duration; ear infections, surgery, perforations and trauma; noise exposure across occupational, military and recreational sources with protection used; family history; medical history and medications; previous tests; and devices already tried. A pediatric audiology case history adds birth and early history, ear infection frequency, speech and language development and school listening environment.

Q: Can this audiology case history form be edited before use?
A: Yes, completely. Rename it, rewrite any question, change which fields are required, switch between adult and paediatric modes, adjust the number of repeating rows for ear history, noise exposure and devices, and add, duplicate, reorder or remove sections.

Q: Can I download or print the form as a PDF without signing up?
A: Yes. No account, no email wall. A default PDF is available immediately, and after any edit a new PDF is generated from your version so the download matches what you see. It is formatted for US Letter with realistic writing space.

Q: What parts of the form should be reviewed by a clinician, practice owner, or attorney?
A: A licensed audiologist should review the history questions for your caseload, and decide which audiology history questions your practice wants at intake versus in the appointment. Your attorney should review consent and, for paediatric use, guardian wording. The form holds no test values, contains no standardised handicap or symptom instrument, and interprets nothing.

Q: Does using a template automatically make a practice HIPAA compliant?
A: No. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, but compliance depends on how your practice stores, transmits and controls access to completed forms, and on the agreements you have in place.