Initial History
Created by
Kim Nguyen
Specialty
Audiologist
Last edited
10/20/2026
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About this template
This template supports adult audiology initial assessments by organising the patient’s hearing and communication concerns, ear and general health history, hearing aid experience, test findings, and follow-up planning. It is intended for comprehensive, explicit-only clinical documentation.
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Adult Initial Assessment
Audiologist: Sarah Jenkins
Date: 14/05/2024
Attended with: Margaret Vance (Wife)
Referrer: Dr David Chen, GP (Subiaco Medical Centre)
History
Reason for assessment: Gradual bilateral hearing decline over 3 years.
Presenting concerns: Wife notes frequent requests for repetition and increased TV volume.
Hearing/communication concerns
General: Speech sounds muffled; feels others are mumbling.
1:1: NAD in quiet environments with visual cues.
Noise/groups: Significant difficulty following conversations in restaurants and family gatherings.
Phone: Prefers using R ear; struggles with unfamiliar accents on mobile.
TV: Volume set to 45/100 (wife prefers 20); relies on subtitles.
Lifestyle: Increasing listening fatigue by evening.
Living situation: Lives in a house with wife.
Work: Retired carpenter.
Social activities: Withdrawing from weekly bowls club social drinks due to background noise.
Other: Difficulty hearing doorbell from back patio.
Tinnitus: Bilateral, constant high-pitched ringing. Non-pulsatile. Worse in quiet, does not disturb sleep.
Ear history
Infections/Discharge: Nil recent. Childhood otitis media (resolved).
Pain: Nil.
Fullness: Occasional mild aural fullness post-swimming, resolves spontaneously.
Surgery: Nil.
Vertigo: History of BPPV (2022), treated successfully by vestibular physiotherapist with Epley manoeuvre. Nil current dizziness.
Noise exposure: 40 years occupational exposure (power tools, machinery); inconsistent hearing protection use.
Family history: Father had presbycusis in 70s.
General health: Well. T2DM (metformin 500 mg PO BD), HTN (perindopril 4 mg PO OD).
Vision issues: Presbyopia, wears multifocal glasses.
Manual dexterity: Mild OA in DIP joints bilaterally, functional fine motor control intact.
Cognitive issues: Nil reported.
Mental health concerns: Nil.
Other: Nil.
Hearing aids
Previous use: Nil.
Perceived need: High motivation; keen to improve communication with family and at bowls club.
Results (see report for full details)
Otoscopy: Clear EAMs bilaterally, TMs intact with normal landmarks.
Tymps
Right: Type A
Left: Type A
Audiometry: Mild to moderate sloping symmetrical sensorineural hearing loss (SNHL) bilaterally, with a 4 kHz notch consistent with NIHL and presbycusis.
Speech discrimination: R: 92 % at 65 dB HL; L: 90 % at 65 dB HL. Roll-over absent.
OAE's (if applicable)
Reason for testing: Outer hair cell function verification.
Result: DPOAEs present 1–1.5 kHz, absent 2–8 kHz bilaterally.
ABR (if applicable)
Reason for testing: Not clinically indicated (symmetrical SNHL with good speech discrimination).
Result: Not performed.
Tinnitus questionnaires if applicable: Tinnitus Handicap Inventory (THI): Score 18/100 (Grade 2 - Mild).
Further action
Discussion: Explained audiogram results, impact of high-frequency loss on consonant clarity in noise, and correlation with occupational noise history.
Recommendations: Binaural amplification, communication tactics in noise, and sound enrichment via amplification for tinnitus management.
Report to: Dr David Chen (GP) and client.
Hearing aid selection: Phonak Audéo Lumity L70-R (RIC) bilaterally with vented domes.
Special considerations: Rechargeable units selected to accommodate mild hand OA.
COSI: 1. Hear wife clearly in the car; 2. Follow group conversation at bowls club; 3. Reduce TV volume to comfortable level for family.
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