Initial History

Adult initial assessment: Audiologist: Dr. Emily Carter Date: October 15, 2023 Attended with: John Doe Referrer: Dr. Sarah Johnson, General Practitioner History: Reason for assessment: Routine hearing evaluation due to age-related concerns Presenting concerns: The patient reports difficulty understanding conversations in noisy environments and frequently asks others to repeat themselves. Hearing/communication concerns: General: Difficulty hearing in crowded places 1:1: Struggles to follow conversations in quiet settings Noise/groups: Significant challenges in group conversations Phone: Often misunderstands phone conversations TV: Needs to increase TV volume significantly Lifestyle: Avoids social gatherings due to hearing difficulties Living situation: Lives alone in a quiet neighborhood Work: Retired, no work-related concerns Social activities: Reduced participation in community events Other: None reported Tinnitus: Occasional ringing in both ears Ear history: Infections/Discharge: No history of infections or discharge Pain: No ear pain reported Fullness: Occasional sensation of fullness in the right ear Surgery: No history of ear surgery Vertigo: No vertigo experienced Noise exposure: Worked in a factory for 20 years Family history: Father had age-related hearing loss General health: Generally healthy Vision issues: Wears glasses for reading Manual dexterity: No issues Cognitive issues: No cognitive concerns Mental health concerns: Mild anxiety Other: None Hearing aids: Previous use: Never used hearing aids Perceived need: Believes hearing aids may improve quality of life Results (see report for full details): Otoscopy: Normal appearance of ear canals and eardrums Tymps: Right: Type A Left: Type A Audiometry: Mild to moderate sensorineural hearing loss bilaterally Speech discrimination: 80% in quiet settings OAE's (if applicable): Reason for testing: To assess cochlear function Result: Normal OAE responses ABR (if applicable): Reason for testing: Not applicable Result: Not applicable Tinnitus questionnaires if applicable: Mild impact on daily life Further action: Discussion: Discussed results and implications with the patient Recommendations: Consider trial of hearing aids, follow-up in 6 months Report to: ENT, GP, Client Hearing aid selection: Recommended behind-the-ear model with noise reduction features Special considerations: Ensure comfort and ease of use COSI: Patient aims to improve hearing in group settings and on the phone