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

 
 
 

What is your hearing aid experience?







If you wear a hearing device do you wear it in your  
    

Please rank the following from 1 to 4 in terms of importance to you when purchasing a hearing device

(1 = MOST important and 4 = LEAST important).
 

Please indicate your ability to hear in the situations below and how often you are in that situation

 
How well do you hear in a quiet room?
  
How often are you in this situation?
 
 
How well do you hear listening to the television?
  
How often are you in this situation?
 
How well do you hear listening to music?
    
How often are you in this situation?
   
 
How well do you hear in restaurants?
    
How often are you in this situation?
    
 
How well do you hear in church? 
   
How often are you in this situation?
 
 
How well do you hear at meetings or lectures?
   
How often are you in this situation?
    
 
How well do you hear at your workplace?
    
How often are you in this situation?
   
 
How well do you hear on the telephone?
    
How often are you in this situation?
   
 
How well do you hear in the car?
     
How often are you in this situation?
   
 
How well do you hear at mealtimes at home?
     
How often are you in this situation?
     
 
How well do you hear in groups of 4-6 people?
    
How often are you in this situation?
     
 
How well do you hear on a city street? 
     
How often are you in this situation?
   
 
How well do you hear in large social groups?
     
How often are you in this situation? 
     
 
How well do you hear the radio?
 
How often are you in this situation? 
     
 
How well do you hear shopping?
     
How often are you in this situation? 
     ​​​​