Patient Intake Form

1
Name* This field is required.
First Name
Middle Name
Last Name
2
E-mail
3
Address:* This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Home Phone
Area Code
Phone Number
5
Cell Phone
Area Code
Phone Number
6
Date of Birth* This field is required.
Month
Day
Year
7
Sex
Male
Female
N/A
Gender
8
How may we contact you? (mark all that apply)* This field is required.
Home Phone
Cell Phone
E-mail
Mail
Text
9
Marital Status
Single
Married
Divorced
Widowed
10
Partner's Name (if applicable)
11
The following questions are about your medical history
12
Who is your Primary Care Doctor?
13
What is your doctor's phone number (if known)
14
Are you currently taking any medications?* This field is required.
Yes
No
15
How many?
16
Do you have diabetes* This field is required.
Yes
No
17
Do you have high blood pressure?* This field is required.
Yes
No
18
Do you take blood thinners?* This field is required.
Yes
No
19
Do you have a history of ear infections?* This field is required.
Yes
No
20
When was your most recent one?
21
Have you had any type of ear surgery?* This field is required.
Yes
No
22
Please explain
23
Have you had a head injury?* This field is required.
Yes
No
24
Please explain
25
Have you ever been told by a doctor that you have Meniere's disease?* This field is required.
Yes
No
26
Are you experiencing any of the following symptoms?
27
Hearing Loss?* This field is required.
Yes
No
28
Age of onset?
29
How suddenly did it happened?* This field is required.
Gradual
Sudden
Fluctuant
30
Do you hear ringing, chirping or whooshing in your ears?* This field is required.
Yes
No
31
In which ear?
Right
Left
Both
Unsure
32
Are you experiencing pain in your ears?* This field is required.
Yes
No
33
Since when?
34
Are you experiencing discharge from the ear(s)?* This field is required.
Yes
No
35
Since when?
36
In which ear?
Right
Left
Both
37
Are you experiencing fullness or pressure in the ear?* This field is required.
Yes
No
38
Since when?
39
In which ear?
Right
Left
Both
40
Are you experiencing dizziness?* This field is required.
Yes
No
41
How often?
42
Are you experiencing nausea?* This field is required.
Yes
No
43
How often?
44
The following questions are about your hearing
45
How would you describe your hearing ability?* This field is required.
Poor
Fair
Good
Excellent
46
Is your hearing the same in both ears?* This field is required.
Same
Better on right ear
Better on left ear
Unsure
47
Have you had a hearing evaluation before?* This field is required.
Yes
No
48
When and where?
49
What were the test results?
No loss
Hearing loss
50
Have you tried hearing aids before?* This field is required.
Yes
No
51
How long ago?
52
Model and style?
53
Do you currently use hearing aids?* This field is required.
Yes
No
54
In which ear?
Right
Left
Both
55
What concerns do you have with your current devices or ones you tried before?
56
Do you have trouble hearing the following?* This field is required.
TV
Phone
Speech-in-noise
General conversations
57
Who else in your family has or had any hearing loss?
58
How motivated are you (psychologically, emotionally and financially, etc..) regarding doing something about your hearing loss?* This field is required.
Not at all
Somewhat Interested
Almost ready
Very motivated
59
Do you have budget concerns or limitations?
YESNO
60
What are they?
Huge
Large
Normal
Small
Ok
Ok
61
Please tell us what is important to you regarding hearing aids if you were to need them...
62
Please check all that applies
Sound quality and clarity
Durability/reliability
Cost
Appearance
63
FINANCIAL POLICY

Unless otherwise indicated, payment on your account (if any) is due at the time services are rendered. We will clearly explain to you any charges prior to rendering any services. You will also be informed prior to us rendering services if we are contracted with your insurance. When applicable, all services and products not paid for by your insurance are your responsibility. Many insurance companies will reimburse the insured (you) directly, in this case we can supply you with the necessary information so that you can submit a claim, otherwise when contracted we will submit the claim.

We highly recommend that you verify benefit coverage with your insurance to ensure that you receive the same information from them as we have. Mt. Hood Hearing cannot be held responsible for any unpaid claims by your insurance company to you.
64
Financial Policy * This field is required.
65
Authorization to contact by mail, phone or email* This field is required.
66
Acknowledgement of receipt of notice (HIPAA)* This field is required.
67
Release of records
68
In order to keep your health information confidential, we ask you to designate with whom the staff at Mt. Hood Hearing may discuss test results, hearing aid, insurance and/or financial information.
69
Would you like to authorize someone on your account for us to speak to regarding your records?* This field is required.
No (Only disclose information to myself)
Yes, I would like to authorize someone on my account
70
Name
First Name
Last Name
71
Contact Number
Area Code
Phone Number
72
How is this person related to you?
73
Would you like to designate someone else?ie: Daughter
YESNO
74
Name
First Name
Last Name
75
Contact Number
Area Code
Phone Number
76
How is this person related to you?ie: Daughter
77
Would you like to designate someone else?
YESNO
78
Name
First Name
Last Name
79
Contact Number
Area Code
Phone Number
80
How is this person related to you?ie: Daughter
81
Signature* This field is required.
Clear
82
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