Cochlear Implant Consultation Form

Date

Person completing this form

Relationship to patient

Patient Name

Birthdate

Gender

Male Female Other Prefer not to say

Address

Street Address

City

State / Province

ZIP / Postal Code

Living Situation

Home Phone

Cell Phone

Alt. Phone

Work Phone

Email

What is the best way to contact you during the daytime? (Please be aware that we are unable to send texts)

Work Phone E-mail Main Phone Alt. Phone

Employment

Primary Language/Language(s) spoken at home

Sign language interpreter needed:

Yes No

Occupation

Place of Employment

What is the highest level of education you have completed?

Less than high school High school diploma/GED Some college Bachelor's degree Graduate degree

When did you first notice your hearing loss?

Was the onset of your hearing loss

Sudden Gradual

If sudden, please describe the onset in detail:

When were you officially diagnosed with hearing loss?

Has your hearing loss changed over time?

Yes No

Please provide details:

Did you lose your hearing in both ears at the same time?

Yes No

Is there one ear that is your "better hearing ear"?

Yes, right ear Yes, left ear No

When and where was your last hearing test?

Do you know the cause of your hearing loss?

Yes No

If yes, please check all that apply:

Describe any selected above:

Is there any hearing loss within your immediate or extended family?

Yes No

If so, for whom, what was the diagnosis, and at what age?

Have you had frequent exposure to any of the following? (Check all that apply)

Loud music Firearms Industrial/factory noise Power tools Aircraft/engine noise None of the above

If yes, did you wear ear protection during this exposure?

Yes No Sometimes

Please provide details

Did you serve in the military?

Yes No

If yes, what service and how many years?

Please indicate if you have ever experienced any ringing in the ears:

Yes, constantly Yes, occasionally No

Please provide details if you experience(d) dizziness or imbalance:

Have you had any medical imaging of your ears or head?

Yes No

If yes, what type of imaging?

CT scan MRI X-ray Other

Please describe below what kind(s) of amplification devices you have tried or currently use (please check all that apply):

Hearing aid(s) Cochlear implant Bone-anchored hearing device None

What device(s) do you currently use?

Where and from whom were the device(s) dispensed?

How many hours a day do you wear the device(s)? If you do not wear your device(s) full time, what prevents full-time use?

What is your preferred method of distance communication with friends and family?

Are you able to understand spoken language via the telephone?

Yes No Sometimes

Have you ever used an FM system to understand speech in noise or at a distance?

Yes No

If yes, please describe the FM system and when it was/is used

Have you ever used any other form of assisted listening device? (i.e., amplified telephone, loop systems, etc)

Yes No

If yes, please describe the technology and how it is/was used

Have you ever used any type of alerting device for sounds you cannot hear? (i.e., visual doorbell, vibrating alarm clock, etc.)

Yes No

If yes, please describe the technology and how it is/was used:

Please list below or provide an attached list of your current medications:

Have you ever been treated with the following:

Chemotherapy Radiation therapy Ototoxic medications None of the above

Are you allergic to anything?

Yes No

If yes, please list and describe?

Do you use a cane, walker, or wheelchair to get around?

Yes No

If yes, how often do you use the assistive device?

Have you ever been diagnosed with or treated for any of the following? (If the answer is no, please leave blank)

Diabetes Heart disease High blood pressure Meniere's disease Tinnitus Autoimmune disorder Neurological condition

Please explain any "yes" or "not sure" answers. If you have any other formal diagnosis not listed above, please describe below:

Please list any surgeries, hospitalizations, accidents, or injuries you have had below. Please include specifics (i.e., where you were hospitalized/treated, when, and for what reason):

If you have any other formal diagnosis not listed above, please describe below

When was your last vision test?

Do you have vision loss?

Yes No

If yes, check all that apply below

Do you wear glasses?

Yes No Sometimes

If yes, is your vision corrected to normal?

Yes No

Social and Emotional Impact of Hearing Loss

With whom do you spend most of your time?

Who are the most important people in your life?

What effect has your hearing loss had on you and those closest to you?

If you are currently employed, what challenges do you face at work because of your hearing loss?

What activities are you involved in within or outside of your home?

How has hearing loss affected these activities?

On a rating scale of 1 to 10, how interested are you in receiving a cochlear implant and why?

What do you hope to gain with a cochlear implant?

What are your greatest fears regarding cochlear implantation?

What questions would you like answered during your cochlear implant candidacy evaluation?

Is there any other information of which you feel the team should be aware?

Were you referred for this assessment?

Yes No

If yes, by whom?

Listening Ability Assessment: rate each of the following situations

All cochlear implant recipients are able to understand speech at initial activation.

True False

Speech will sound natural to all cochlear implant recipients.

True False

Cochlear implant recipients no longer need to speech read/lip read.

True False

Cochlear implant recipients can understand speech in background noise easily.

True False

Television programs are easy to understand for cochlear implant recipients.

True False

Cochlear implant recipients report that music sounds natural.

True False

All cochlear implant recipients can determine the location of a sound without visual cues.

True False

All cochlear implant recipients can communicate over the telephone.

True False

Insurance will cover all equipment costs.

True False

Cochlear implant recipients no longer have hearing loss.

True False

All cochlear implant recipients eventually have the same hearing abilities.

True False

Cochlear implant recipients will lose their natural hearing in the ear implanted after surgery.

True False

The recipient's outcomes are dependent on how much hearing loss they had prior to implantation.

True False

The recipient's outcomes are dependent on whether they used a hearing aid prior to implantation.

True False

The recipient's outcomes are dependent on how much they use their devices.

True False

Please let us know if you would like more information or are interested in any of the following opportunities listed below:

Support group meetings Speaking with a current recipient Educational materials Scheduling a follow-up appointment None at this time

Primary Care Physician

Location

Primary Insurance

Secondary Insurance

Other

Please complete and attach with this form:

Audiogram Insurance card copy Physician referral Medical records release form

File Upload

Max 10 MB per file

Office Use Only

Thank you for completing this consultation form. Our team will contact you to schedule your evaluation.

Cochlear Implant Consultation Form

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