This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: Fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submission.

Preferred Location:   

Patient Information

Chief Complaint (Choose one)


Is this a problem due to work injury or exposure?

   

Do you feel your hearing is changing?

  

How would you describe the change?
  

Have you ever been exposed to loud noise, either recently or in the past?



Select all that apply:
 
 
 
 
 
 
 

Have you seen an ear, nose and throat physician?


Have you ever had surgery that may have affected your hearing?

 

Is there a history of hearing loss in your family?

 

Have you ever had an ear infection?

 

If yes, was it:
  

Have you, in the past 10 years, experienced chronic or acute dizziness, light-headiness, or vertigo?

  

Do you take any prescription medications? *Required for medicare patients

Medicare patients only: Are you a smoker?

 

Please check off any of the following that you currently have or have had in the past:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


If a hearing aid was recommended for you, please rank the following in order of importance.

(1 is most important, 4 is least important)

If you are currently using a hearing aid, or have in the past, please answer the following:

Which ear is aided?