New Patient History Form
Cochlear Implant(s)
Name
*
Prefix
First Name
Last Name
Preferred Name
Date of Birth
*
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Gender
*
Please Select
Male
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Transgender
Non-binary/Non-conforming
Preferred Pronouns
ex. they/them
How would you prefer we contact you?
*
Email
Video chat
Texting
Phone call - cell phone
Phone call - home phone
Other
Email
*
example@example.com
Phone #1
*
-
Area Code
Phone Number
Phone #1 Type
Cell
Home
Work
TTY
Phone #2
-
Area Code
Phone Number
Phone #2 Type
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Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
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Country
How did you hear about The Hearing Solution's CI services?
*
Do you currently have a cochlear implant or bone conduction device?
Please Select
no
Yes- Cochlear Americas
Yes- Advanced Bionics
Yes- Med-El
Yes- Oticon Medical
Yes- other
What CI service(s) do you currently need?
*
e.g. mapping, troubleshooting, upgrade services
Do you have Medicare?
Yes
No
In order to bill Medicare for your services, we need a referral from your primary care physician. Has a referral been sent to our office already?
Primary Insurance Company:
*
Primary Insurance ID#:
*
Secondary Insurance Company:
Secondary Insurance ID#:
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Cochlear Implant History
Which ear has a CI?
*
Right ear only
Left ear only
Both ears (bilateral)
Neither ear
CI surgeon, hospital, date of surgery, and any major complications:
ex. Dr. Smith, SF General Hospital, June 2001
CI brand
Advanced Bionics
Cochlear Americas
MED-EL
Oticon Medical
Other
Which AB sound processors do you currently use?
Marvel
Naida
Harmony
Neptune
Chorus
PSP
Other
Which Cochlear sound processors do you currently use?
Nucleus 8
Kanso 2
Nucleus 7
Kanso
Nucleus 6
Nucleus 5
Other
Which MED-EL sound processors do you currently use?
Sonnet 2
Sonnet
Rondo 2
Rondo
Opus 2
Other
Which Oticon Medical sound processors do you currently use?
Neuro 2
Neuro 1
Saphyr
Other
Name of audiologist and clinic where most recent CI mapping was done:
ex. Rachel Bellotti, AuD, at The Hearing Solution in Sacramento, CA
Email address of CI audiologist:
example@example.com
Any issues or concerns you have about your current CI audiologist/clinic:
Is any of your CI equipment currently broken or not working correctly?
ex. broken cable, battery, microphone
Have you ever had a CI surgically removed?
Yes
No
Regarding the CI removal, please describe the basics: when, why, any complications, etc.
ex. October 2005 by Dr. Smith at SF General Hospital, because the device stopped working
Cause of hearing loss:
ex. loud noise exposure, genetics, unknown
Age when hearing loss was first detected:
ex. 35 years old for right ear and 50 years old for left ear
Age when hearing loss became severe-profound:
In other words, what age were you when you first qualified for a cochlear implant?
Have you ever used a hearing aid in either ear? When and for how long?
ex. from age 30 to 50 in the right ear and never in the left ear
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Health Concerns and Changes
Do you have any medical and/or mental health conditions you would like us to know about or that may affect your CI care?
*
Have you had any recent and/or significant changes to your overall health or well being?
*
Are you currently experiencing:
*
Yes
No
Ear pain
Pressure or fullness in the ear(s)
Ear infection(s)
Drainage from your ear(s)
A recent head trauma
Ringing/buzzing/tinnitus in your ears
Sudden/progressive hearing loss in the last 90 days
If you selected "Yes" for any of the above issues, please explain further:
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Optional: Hearing Performance
These questions are optional.
What environments or situations would you like to hear better in?
Make a list of the loved ones you communicate with most often:
Are you interested in any of the following audio streaming technologies?
iPhone
Android
Landline phone
Desktop computer, laptop, tablet, or iPad
FM
Television
Telecoil and loop systems
Remote microphone (i.e., a microphone someone else wears)
Other
How much difficulty do you have hearing in the following situations?
No Difficulty
Slight Difficulty
Moderate Difficulty
Very much difficulty
Not Relevant
One on one conversations
Conversations in small groups
Conversations in large groups
Outdoors
Concerts/Theaters
Place of worship/lecture halls
Watching TV
In a car
Landline Phone
Cell Phone
Restaurants
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If you have any documents you would like to send us, please upload them here:
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Notice of Privacy Practices and Right to Bill
Please review and check the following boxes:
I allow for voice messages from this practice to be left on any provided phone number.
I allow for text messages from this practice to be sent to my mobile number.
I give permission to this practice to release information, verbal or written, contained in my medical record and other related information to my insurance company, healthcare providers, assignees and/or beneficiaries and all other related persons.
On occasion, The Hearing Solution sends out newsletters or birthday cards. I allow for The Hearing Solution to contact me by mail or e-mail for promotional reasons.
I acknowledge that I have had the opportunity to review a copy of The Hearing Solution’s privacy notice. (Available to view on our website and in the office.)
I hereby authorize all benefits for charges of examination and/or treatments requested to be paid to The Hearing Solution. Verification of insurance coverage obtained over the phone does not guarantee payment. I have read this statement and accept full financial responsibility for all medical charges incurred by my dependents or me for services rendered by The Hearing Solution.
I allow the following individuals (eg. spouse/family members/caregivers) to be allowed access to my information regarding my hearing and ongoing treatments for the duration of my care, unless The Hearing Solution is notified otherwise:
(ex. spouse/caregivers/family members)
Signature
Date
-
Month
-
Day
Year
*
I have read the above form and acknowledge receipt of all information
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