Hearing Loss Screening Test Comprehensive Hearing Assessment Comprehensive Hearing Assessment Questionnaire Patient Details Name: Age: Gender: Select Male Female Other Phone Number: Address: Hearing Complaint 1. Hearing loss is: Bilateral Unilateral 2. Onset: Sudden Gradual 3. Course: Stable Progressive Fluctuating 4. Better hearing in noisy environment? Yes No Associated Ear Symptoms Ear fullness / blocked sensation Ear discharge Ear pain Tinnitus Balance Symptoms Vertigo Imbalance Risk Factors Occupational / loud noise exposure Head / ear trauma Ototoxic drug exposure Family history of hearing loss Generate Result Assessment Summary Advanced Hearing Loss Screening Advanced Hearing Assessment – Malleus ENT Clinics Advanced Hearing Assessment Questionnaire Patient Details Name Age Gender Select Male Female Other Phone Number Address Hearing Complaint Laterality Bilateral Unilateral Onset Gradual Sudden (within 72 hours) Course Stable Progressive Fluctuating Which sounds are more difficult to hear? High-pitched sounds Low-pitched sounds Both equally Do you hear sounds but have difficulty understanding speech? Yes No Better hearing in noisy environment (Paracusis)? No Yes Associated Ear Symptoms Ear fullness Ear discharge Ear pain Tinnitus Autophony (loud own voice/breathing) Balance Symptoms Vertigo Imbalance Risk Factors Noise exposure Ototoxic drug exposure Head / ear trauma Family history Hearing problem since childhood Red-Flag Symptoms Facial weakness / numbness Headache / visual symptoms Functional Handicap Mild Moderate Severe Generate Consultant-Level Assessment
