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 submissions

* Required Fields

Name

Spouse

Address

City

State

Zip Code

Phone

Cell

Work Phone

Male Female

Birth Date

Occuptation

Retired? Yes No

Family Physican

Phone

City

ENT Physican

Phone

City

Referred by:

Did your occupation or other activities expose you to loud noise?

Yes No

Describe the noise exposure

Preferred Language

Other Languages Spoken

How did you find out about our Center?

What are your reasons for scheduling this appointment?

What do you think may have caused your hearing problem?

Has your hearing changed since you first noticed a problem (e.g. improved or worsened)?

IF A HEARING LOSS IS DISCOVERED, ARE YOU READY FOR HELP?

Yes No

Medical Waiver:
I have been advised by the undersigned, that the Food & Drug Administration has determined that my best interest would be served if I had a medical evaluation by a licensed physician (preferably by a physician who specializes in diseases of the ear) before I purchase a hearing aid. I understand that the testing information herewith was communicated and am 18 years of age or older.

Signature

Spouse

Medical History

Are you presently under the care of a medical specialist (e.g. neurologist, ear-nose-throat (ENT) specialist) or other?

Yes No

If yes, Please list each specialist’s name and type of specialty:

Please list daily medication taken and for what:

Is there a history of hearing loss in your immediate family? Please list relationship:

When was your most recent hearing test, or will this be your first hearing test?

Have you ever had any surgery on your ears? If so, please describe the surgery performed:

Will this be your first hearing test?

Yes No

Have you been examined by a doctor in the past six months?

Yes No

Have you ever had ear surgery?

Yes No

Have you ever experienced any of the following:

Deformity of the ear?

Yes No

Ear drainage in the past 90 days?

Yes No

Sudden or rapid hearing loss in the past 90 days?

Yes No

Sudden or rapid hearing loss in the past 90 days in one ear only?

Yes No

Unilateral hearing loss of sudden or recent onset within the previous 90 days?

Yes No

Acute or reoccurring dizziness?

Yes No

Have you had a doctor remove wax from your ears?

Yes No

Are you experiencing ear pain now?

Yes No

Which is your worst ear?

Right Left Same

Tinnitus or ringing in your ears affects many people. Please answer the following:

Do you have any tinnitus symptoms?

Yes No

When did you first notice it?

Recently 1-3 years 4-10 years 10+ years

In which ear do you notice your tinnitus?

Right Left Same

Have you been seen by a physician for evaluation and treatment your tinnitus?

Yes No

Do you know the cause of your tinnitus? If so, please describe:

What is your emotion toward your tinnitus?
Curious Distressed Concerned Adaptation

What else can you tell me about your tinnitus?

Do you sometimes hear conversations loud enough, but cannot understand the words?

Yes No

Do you often ask others to repeat what they have just said?

Yes No

Do you find it difficult to understand conversation in noise?

Yes No

Do others notice you play the TV or radio too loud?

Yes No

Do you have trouble understanding some people on the telephone?

Yes No

How many years have you experienced hearing and understanding difficulty?

Do you currently wear hearing aids?

Yes No

If so, how old are your current aids?

Which ear do you normally use on the telephone?

Right Left

Have you ever avoided a social situation because you cannot hear? Describe the situation.

Does trying to hear cause you to be fatigued or frustrated?

Yes No

Can you hear car horns, sirens, smoke alarms?

Yes No

Have you ever used hearing aids in the past?

Yes No

If so, what did you like about the hearing aid(s)?

What did you not like about the hearing aid(s)?

Is there anything else that you would like us to know?