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.

Personal Information

Preferred Title

 Mr.

 Mrs.

 Ms.

 Dr.

First Name (required)

Middle Name

Last Name (required)
Preferred Name

Gender

 Male

 Female

Date of Birth (required)

Address(required)

City (required)

State (required)

Zip (required)

Cell Phone (required)

Other Phone

Email (required)

Occupation

How would you like to be contacted?

 Phone

 Email

 Mail

Spouse Name

Spouse Date of Birth

Insurance Carrier

Insurance ID
Secondary Insurance Carrier (if applicable)

Secondary Insurance ID
Emergency Contact Name (required)

Emergency Contact Name Phone (required)

Doctor Name

Doctor Phone

Who can we thank for referring you to our office? We like to know how our patients find our practice. Please check the MOST influential source of information about this practice.

 Physician

 Family Member

 Friend

 Newspaper

 Mailing

 Radio

 Co-Worker

 Internet

 Health Plan

 Other

Name of Referral

Release of Medical Information

I herby authorize Carson Hearing Care, PLLC, to release any and all medical information in the course of my (or my child’s) treatment to:

 Primary Care Physician

 Spouse

 Children

 Caretaker

 Nursing Facility

Date

I have been given the opportunity to read or obtain a copy of the Notice of Privacy Practices and HIPAA release/authorization.

  Agree

Patient/Parent/Guardian Signature (required)

Case History

What is your main concern?

 Difficulty Hearing

 Tinnitus/Ringing in the Ears

 Dizziness

With which ear do you hear best?

 Left Ear

 Right Ear

 Same/Not Sure

When do you have difficulty hearing?

 In Quiet

 In Noise

How would you rate your hearing from 1-10. (1 being poor, 10 being excellent) (required)
How long have you noticed difficulty hearing? (required)

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

 Yes

 No

Have you seen an Ear, Nose, & Throat Physician (ENT)?

 Yes

 No

If So: when was your last visit?

ENT's Name

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

 Yes

 No

Have you ever had an ear infection?

 As a Child

 As an Adult

Is there a history of hearing loss in your family?
Do you take any prescription medications on a regular basis? Please list below.
Do you take Aspirin or any other blood thinners? If so: Name of medication
How often do you take blood thinners?

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

 High Blood Pressure
 Heart Trouble
 Pacemaker
 Measles
 Head Injury
 Meningitis
 Diabetes
 Parkinson's
 Bell's Palsy
 Cancer
 Radiation
 Chemotherapy

If you had cancer, what type was it?

Have you had a fall or near fall in the past year?

 Yes

 No

If you have worn a hearing aid in the past, which ear was aided?

 Left Ear
 Right Ear
 Both Ears

How long have you used a hearing aid?

What would you improve about your current aid?

In what situation would you or others say you have difficulty hearing? (required)

What is your primary goal for today’s visit? (required)