Cochlear Implant Candidacy Medical History Form

This specialized medical history form supports audiologists and otolaryngologists in evaluating patients for cochlear implant candidacy. It captures comprehensive information about the onset, progression, and impact of hearing loss, including age at onset, suspected causes, family history of hearing impairment, and current communication methods. The form documents previous interventions including hearing aid trials, assistive listening devices, and surgical history related to ear conditions.

The template includes critical sections for medical contraindications such as cochlear ossification, inner ear malformations, and conditions affecting anesthesia safety. It assesses patient motivation, realistic expectations, family support systems, and participation in aural rehabilitation programs. Additional components cover MRI compatibility concerns, vaccination history for meningitis prevention, developmental milestones for pediatric candidates, and speech perception testing results. This comprehensive approach ensures appropriate candidate selection and pre-surgical planning for cochlear implantation programs.