Patient Registration Form All Ages

Name*

PrefixFirst NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Primary Care Physician*
Referring Physician*
Which language would you prefer to use during your appointment?
Responsible Party

Parent or Guardian
Name*

PrefixFirst NameLast Name
Relationship to patient*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Home Phone *

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Occupation*
Email*
example@example.com
Marital Status
Spouse
Other legal guardian (if applicable) and relationship to patient?
Insurance Information
Insurance Information: Please disclose ALL insurance coverage/policies and give all cards to the front desk. Failure to do so may result in charges becoming patient responsibility.
Primary Insurance*
Policy Holder*
Policy Holders Birthdate*

MonthDayYear
Date
Policy Holders Member ID #*
Secondary Insurance
Policy Holder
Policy Holders Birthdate

MonthDayYear
Date
Policy Holders Member ID #
Informed consent agreement

I understand that the evaluation of the hearing/speech systems requires the use of specialized instrumentation. During the course of this evaluation, I understand that various earphones will be placed over my ears and various probes may be placed in the external ear canal. In the event amplification or other custom devices are required, I consent to placement of foam or cotton blocks in the external ear as well as, materials to make ear impressions.

I do hereby authorize Acadian Hearing Services to submit claims to my insurance company/companies on my behalf, and my insurance company/companies to make payments directly to Acadian Hearing Services for professional services rendered.

I UNDERSTAND I AM RESPONSIBLE FOR ANY DEDUCTIBLE, CO-PAYMENT, AND OTHER AMOUNTS NOT COVERED BY MY INSURANCE COMPANY/COMPANIES. I ALSO UNDERSTAND THAT FAILURE TO CANCEL ANY APPOINTMENT WILL RESULT IN A $50 NO SHOW FEE THAT I WILL BE RESPONSIBLE FOR. I/we agree to be bound by the above terms and conditions.

As required by HIPAA ACT 1996, I have read and understood the notice of privacy practices for this practice and a copy has been made available to me.
Signature*

Clear
Date*

MonthDayYear
What Age is the Patient?
What Age is the Patient?*
Pediatric Medical History
Form completion date

MonthDayYear
Name of hospital where child was born*
What is the birth mothers maiden name?*
Did the baby pass the newborn hearing screening at birth?*

YesNoUnsure
Which ear (if any) failed the newborn hearing screening test?

RightLeftBoth
Was the child's birth on time?*

YesNo
If not, how premature or late was the birth?
Baby's birth weight?
Did the baby require oxygen at birth?*

YesNo
Was the baby blue at birth?*

YesNo
Was the baby jaundiced (yellow) at birth?*

YesNo
Did the mother take any medication/drugs whilst pregnant? Please list:*
Were there any other problems at birth? If so, explain:*
What is the reason for your visit today?*
Please list any school related problems.
Please list all of your child's medications
Has your child ever had ear surgery?*

YesNo
If yes, please describe:
Has your child ever had any other surgeries?*

YesNo
If yes, please describe:
Has your child had a hearing test?*

YesNo
If yes, when?
Please check all that have ever applied to your child:*

MeningitisTonsilitisEar infectionsMumpsAllergiesEar drainageEar painHeadachesHead injurySpeech difficultiesVision difficultiesMotor problemsADD/ADHDAutismOther
Is there a family history of hearing loss? If so, who?
Adolescent Medical History
Form Completion Date

MonthDayYear
Date
What is the reason for your visit today?*
Please list any school related problems.
Please list all of your child's medications
Has your child ever had ear surgery?*

YesNo
If yes, please describe:
Has your child ever had any other surgeries?*

YesNo
If yes, please describe:*
Has your child had a hearing test?

YesNo
If yes, when?
Please check all that have ever applied to your child:*

MeningitisTonsilitisEar infectionsMumpsAllergiesEar drainageEar painHeadachesHead injurySpeech difficultiesVision difficultiesMotor problemsADD/ADHDAutismNoise exposure (hunting, shooting)Other
Is there a family history of hearing loss? If so, who?
Adult Medical History
Form Completion Date

MonthDayYear
Date
What is the primary reason for your visit today?*
Medical History - Do you have now, or have ever had any of the following: (please tick all that apply).*

DiabetesHigh Blood PressureStrokeKidney DiseaseThyroid ProblemsArthritisCancerRadiation TherapyChemotherapyChronic Lung DiseaseTuberculosisHepatitisSeizure DisorderAsthmaGlaucomaMacular DegenerationEye Disease - otherIrregular Heart BeatHeart AttackHIV/AidsAlcoholismPsychiatric TreatmentDrug AddictionParkinson's DiseaseDementiaAlzheimer's DiseaseOther
List and date any operations you have had*

How do you feel your hearing is?*
Describe where you are noticing hearing difficulties*
Have you ever had a hearing test before?*
If yes, briefly explain the results
Do you currently or have you ever worn a hearing aid?*
If yes, please list the style, brand, year purchased and which ear
If recommended, are you interested in improving your hearing with a hearing aid?*
Does hearing loss run in your family?*
If yes, whom?
Do you have a history of noise exposure or noisy hobbies?*
If yes, describe (Ex. hunting, at work, carpentry, etc)
Do you have tinnitus (ringing, hissing, buzzing, etc)?*
If yes, which ear, when did it first being and how long does it last?
Do you have any dizziness, loss of balance or lightheadedness? *
1. How often do you experience vertigo (a spinning sensation or feeling off-balance)?*

DailyWeeklyMonthlyRarelyNever
2. When did you first notice your vertigo symptoms?*

Less than a month ago1-6 months ago6-12 months agoOver a year ago
3. How long does your vertigo typically last?*

A few secondsA few minutesA few hoursSeveral days or more
4. Are your vertigo episodes triggered by specific actions or situations? (Check all that apply)*

Turning your head quicklyLying down or getting upRolling over in bedStress or anxietyLoud noisesCertain movements or activitiesOther
5. Do you experience any of the following along with vertigo? (Check all that apply)*

Nausea or vomitingHearing lossRinging in the ears (tinnitus)Pressure or fullness in the earsVisual disturbances (e.g., double vision, blurred vision)Headaches or migrainesDifficulty walking or maintaining balanceOther
6. Have you ever been diagnosed with any of the following conditions?(Check all that apply)*

Ménière's diseaseBenign paroxysmal positional vertigo (BPPV)Vestibular migraineLabyrinthitis or vestibular neuritisOther
7. Have you noticed any patterns or factors that worsen your vertigo?*

NoOther
8. Have you sought medical treatment for your vertigo before?*

NoYes
Which medications? (please list)*
Vestibular rehabilitation therapy*

NoYes
Other treatments (please specify)*
Effectiveness (please describe)*
Is there anything else about your vertigo that you'd like to share?*
Choose 1 Only

The room spins for less than one minute when I lie down, roll over in bed or tilt my head backI get temporarily dizzy, light-headed, or off-balance when I stand up, worse if I stand quicklyI have had several episodes of severe vertigo with nausea, lasting for hours at a time, with fullness and noise in one ear that increases when I am dizzyI have had several episodes of severe vertigo, lasting hours at a time, sometimes accompanied by headaches and/or sensitivity to lightI had an episode of constant spinning vertigo and nausea for 1 to 3 days, and I feel like I have not recovered back to normal yetI am unsteady whenever I am on my feet. I am fine while lying or sitting downI don't really feel dizy or off balance, but I am afraid of falling (or have already fallen)None of these describe my symptoms
On a scale of 1 to 10, with 1 being mildly annoying and 10 being debilitating and life altering, how would you rate the severity of your dizziness or imbalance?
Signature*

Clear
Should be Empty:

	Medication	Medical Condition	Dosage	Route (Oral, topical etc)
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2
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4

Responsible Party

Insurance Information

What Age is the Patient?

Pediatric Medical History

Adolescent Medical History

Adult Medical History