Record of personal experiences

This form will give you an idea of the type of questions you may be asked at your appointment. After completing this form, you may wish to print it and take it with you to your appointment as a convenient reminder.

  • How long ago did you first start to experience difficulty with your hearing?

  • Has your hearing changed gradually or suddenly? Please give details in the space below:

  • Can you hear better in one ear than the other? If so, which one?
  • Is there anyone in your family that has a hearing loss? Do they wear a hearing aid? Please give details in the space below:
  • Can you think of examples of situations where your hearing is not as good as it used to be? Are you worried, upset, concerned or annoyed by being unable to hear in this situation? Please give details in the space below:
  • Have you ever experienced any noises - such as buzzing, whistling or ringing - in your ears? If so, please try to describe these noises as best as you can in the space below, including how often you hear them.
  • Think carefully of occasions when you've been exposed to loud noises. Such noises could have occurred at work, as part of a hobby, or any other leisure activity. Use the space below to give details of these occasions:
  • Have you ever had any operations on your ears? If so, please give details in the space below:
  • Have you ever had any ear infections or discharge from your ears? If so, please give details in the space below
  • Do you suffer from any pain in your ears?
  • Please use the space below to note any medication (prescription or otherwise) that you are currently taking, or have taken previously. Include dates if possible.
  • Do you have any problems with your balance? If yes, please describe these problems in the space below. You might want to include any specific examples that you can think of.