Hearing Aid Evaluation Note

Date/Time: [Date and time of encounter]
Location: [Clinic site]
Clinician: [Name, credentials]
Referral Source: [Referring provider / self-referred]
Participants Present: [Patient; spouse/caregiver if applicable]
Communication Accommodations: [interpreter / captioning / written supports / none required] (Specify language or details if relevant.)

Reason for Visit

[Purpose of visit and chief listening complaints] (Use the patient's own words when helpful. Include patient motivation and readiness for amplification.)

Relevant History

[Pertinent otologic and audiologic history] (Concise synthesis including: onset and course of hearing difficulty; laterality; stability/fluctuations; prior hearing aid use with device types, satisfaction, and reasons for discontinuation if applicable; tinnitus; dizziness/vertigo; otalgia; otorrhea; noise or ototoxic exposures; relevant ear surgeries. Include pertinent positives and negatives only.)

[Non-auditory factors relevant to device selection] (Summarize dexterity/vision limitations, cognitive considerations, occupational or lifestyle demands, technology comfort such as smartphone use and willingness to use apps, and preferences regarding cosmetics, rechargeability, telecoil, and budget.)

[Historian] (Document who provided the history if not the patient; omit if patient is sole historian.)

Communication Needs Assessment

Self-Report Instrument: [COSI / APHAB / HHIE / other / not administered] — [administration mode if applicable] — [baseline scores or interpretation, or reason not administered]

Patient Listening Goals: (List 3–5 goals; include situation/environment, the communication problem, importance level, and what improvement would mean to the patient.)

• Goal 1 ([High / Medium / Low]): [Situation/environment]; [Communication difficulty]; [What improvement would mean to patient]
• Goal 2 ([High / Medium / Low]): [Situation/environment]; [Communication difficulty]; [What improvement would mean to patient]
• Goal 3 ([High / Medium / Low]): [Situation/environment]; [Communication difficulty]; [What improvement would mean to patient]

(Include Goals 4–5 only if provided by patient.)

Key Listening Environments: [Most important environments in priority order] (e.g., quiet conversation, small groups, restaurants, car, telephone, TV, workplace)

Audiologic Data Reviewed

[Audiologic evaluation date and source]. [Summary of hearing loss type, degree, and configuration by ear]. [Speech recognition scores with test conditions]. [Relevant tympanometry/otoscopy findings]. [UCL/LDL if obtained]. (If audiologic data are outdated or unavailable, state explicitly and note that recommendations are provisional pending updated testing. Reference attached audiogram if stored separately.)

Red Flag Screening

(Use explicit Present/Absent/Not assessed attestation. Do not infer negative findings from silence; if screening not performed, document why.)

FDA Red Flag Conditions:

• Visible ear deformity: [Present / Absent / Not assessed]
• Active drainage from the ear within the previous 90 days: [Present / Absent / Not assessed]
• Sudden or rapidly progressive hearing loss within the previous 90 days: [Present / Absent / Not assessed]
• Acute or chronic dizziness: [Present / Absent / Not assessed]
• Unilateral sudden hearing loss within the previous 90 days: [Present / Absent / Not assessed]
• Significant air–bone gap: [Present / Absent / Not assessed]
• Significant cerumen accumulation or foreign body in ear canal: [Present / Absent / Not assessed]
• Ear pain (otalgia): [Present / Absent / Not assessed]

Additional Referral Triggers:

• Asymmetric hearing loss beyond clinic threshold: [Present / Absent / Not assessed]
• Unilateral or pulsatile tinnitus: [Present / Absent / Not assessed]
• Unexplained conductive component: [Present / Absent / Not assessed]
• Disproportionately poor word recognition: [Present / Absent / Not assessed]
• Otoscopic abnormalities: [Present (specify) / Absent / Not assessed]

Referral Decision: [No medical referral indicated—screening negative and otoscopy unremarkable / Medical referral recommended to ENT or PCP for (reason) / Patient already under ENT care with (provider and status) / Fitting deferred pending medical evaluation for (reason)]

Assessment

[Clinical synthesis] (Summarize hearing loss type/configuration and functional impact on communication. State candidacy for binaural or monaural amplification. Comment on readiness and expectation realism. Note constraints affecting selection such as ear canal anatomy, dexterity/vision, budget, or cosmetic preferences. If candidacy is uncertain, state why and what additional information is needed.)

Device Recommendation

(Include this section when a recommendation is made. If selection is deferred, document what is needed before finalizing.)

Recommended Configuration:

• Ear(s) to be fit: [Binaural / Monaural] — [Rationale]
• Style: [RIC / BTE / ITE / ITC / CIC / IIC] — [Rationale]
• Coupling: [open dome / closed dome / power dome / custom earmold] — [Venting approach and rationale]
• Technology level: [Entry / Mid / Advanced / Premium] — [Justification tied to prioritized goals and environments]

Feature Rationale: [Features selected and goal-linked rationale] (Document key features such as directionality/beamforming, Bluetooth connectivity, rechargeable battery, telecoil, tinnitus features, etc. Link each to a stated patient goal or environment. List only features that address stated needs.)

Assistive Technology: [Recommended devices and rationale / None indicated] (e.g., remote microphone, TV streamer, captioned telephone, alerting devices)

Counseling Provided

[Counseling summary] (Topics addressed: realistic expectations, performance variation by environment, acclimatization period, communication strategies, daily maintenance, troubleshooting. Note patient questions/concerns, demonstrated understanding, whether written materials were provided, and whether a communication partner participated.)

Coverage and Consent

• Insurance benefit verification: [verified / not verified] — [Outcome if known]
• Non-covered costs reviewed with patient: [yes / no]
• Trial/return period discussed: [yes / no]
• Warranty discussed: [yes / no]
• Patient decision: [proceed with fitting / defer decision / considering OTC / pursuing medical referral first]

Plan

1. [Action item] — [Responsible party] — [Timeframe]

(Include: next appointment type, prerequisites before fitting, device order details if applicable, planned verification approach, referrals placed, and patient actions.)

Clinician Signature: [Electronic signature / Name, credentials]   Date: [Date]