"Patient Intake Form"

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PATIENT INTAKE FORM
CLIENT HISTORY
PLEASE PRINT
Today’s Date ______ - ______ - ______
Last Name ________________________________________
First Name ____________________________________
MI _________
Address ________________________________________________________
o Male o Female o Married o Single o Widow(er)
City __________________________________
State ___________________
Zip _____________
County ___________________
Phone (
) _______ - ___________
E-mail address ________________________________________________________________
Date of Birth ______ - ______ - ______
Past/Present Occupation _______________________________________________________
Accompanying Party or Companion ________________________________
Relationship ____________________________________
Family Physician Name ________________________________
City ________________________
Phone _____________________
Insurance Carrier ____________________________________________
I.D. No./Policy No. ___________________________________
Permission to release a copy of test information to physician? o Yes o No
Patient’s Signature _______________________________
MEDICAL AND HEARING HEALTH HISTORY
Do you have any of the following:
Deformity of the ear?
o Yes o No
Sudden or rapid hearing loss in the past 90 days?
o Yes o No
Pain or discomfort in the ear?
o Yes o No
Acute or recurring dizziness?
o Yes o No
Previous ear infections?
o Yes o No
Active drainage from the ear?
o Yes o No
Have you ever found it necessary to have a doctor remove wax from your ears?
o Yes o No
In which ear have you noticed difficulty hearing?
o Both o Left o Right
Do you have any sinus or allergy problems?
o Yes o No
If yes, please list _________________________________________
Are you a diabetic?
o Yes o No
If yes, are you insulin-dependant? __________________________
Have you had exposure to excessive noise?
o Yes o No
Do you have a history of firearm use?
o Yes o No
Which ear do you use on the telephone?
o Right o Left
Do you have ringing or other noises in your ears? o Yes o No
If yes, which ear? ________________________________________
Have you previously had a hearing test?
o Yes o No
If yes, by whom and when? _______________________________
Have you received any medical or surgical treatment for your hearing loss? o Yes o No
If yes, when? __________________________
Explain _________________________________________________________________
Physician/ENT _______________________________________
City ________________________
Phone _____________________
AMPLIFICATION HISTORY
Are you a current hearing aid wearer? o Yes o No Type _______________________________
Ear fitted: o Both o Left o Right
If yes, and you could improve something about your current hearing aids, what would that be? ________________________________
_______________________________________________________________________________________________________________
Do you know anyone who wears hearing aids? o Yes o No
If yes, who? _________________________________________________
PATIENT INTAKE FORM
CLIENT HISTORY
PLEASE PRINT
Today’s Date ______ - ______ - ______
Last Name ________________________________________
First Name ____________________________________
MI _________
Address ________________________________________________________
o Male o Female o Married o Single o Widow(er)
City __________________________________
State ___________________
Zip _____________
County ___________________
Phone (
) _______ - ___________
E-mail address ________________________________________________________________
Date of Birth ______ - ______ - ______
Past/Present Occupation _______________________________________________________
Accompanying Party or Companion ________________________________
Relationship ____________________________________
Family Physician Name ________________________________
City ________________________
Phone _____________________
Insurance Carrier ____________________________________________
I.D. No./Policy No. ___________________________________
Permission to release a copy of test information to physician? o Yes o No
Patient’s Signature _______________________________
MEDICAL AND HEARING HEALTH HISTORY
Do you have any of the following:
Deformity of the ear?
o Yes o No
Sudden or rapid hearing loss in the past 90 days?
o Yes o No
Pain or discomfort in the ear?
o Yes o No
Acute or recurring dizziness?
o Yes o No
Previous ear infections?
o Yes o No
Active drainage from the ear?
o Yes o No
Have you ever found it necessary to have a doctor remove wax from your ears?
o Yes o No
In which ear have you noticed difficulty hearing?
o Both o Left o Right
Do you have any sinus or allergy problems?
o Yes o No
If yes, please list _________________________________________
Are you a diabetic?
o Yes o No
If yes, are you insulin-dependant? __________________________
Have you had exposure to excessive noise?
o Yes o No
Do you have a history of firearm use?
o Yes o No
Which ear do you use on the telephone?
o Right o Left
Do you have ringing or other noises in your ears? o Yes o No
If yes, which ear? ________________________________________
Have you previously had a hearing test?
o Yes o No
If yes, by whom and when? _______________________________
Have you received any medical or surgical treatment for your hearing loss? o Yes o No
If yes, when? __________________________
Explain _________________________________________________________________
Physician/ENT _______________________________________
City ________________________
Phone _____________________
AMPLIFICATION HISTORY
Are you a current hearing aid wearer? o Yes o No Type _______________________________
Ear fitted: o Both o Left o Right
If yes, and you could improve something about your current hearing aids, what would that be? ________________________________
_______________________________________________________________________________________________________________
Do you know anyone who wears hearing aids? o Yes o No
If yes, who? _________________________________________________