Patient Intake Form - Adult
Your Details
Name
*
First Name
Last Name
Employer
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Email
*
example@example.com
Secondary Email if needed
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you consent to receive text & email communication from Audicles
Yes
No
Insurance Company
Insured Name
Insurance Card (Front & Back)
Browse Files
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Choose a file
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Your Hearing
Reason for today's visit
*
How did you get referred to Audicles?
*
Do you notice or suspect hearing loss?
*
Yes
No
If "Yes", which ear
Left
Right
Both
Please rate the difficulty of hearing between 1 and 5
*
Please Select
1
2
3
4
5
1 is not so difficult, 5 is very difficult
Is there tinnitus present?
*
Yes
No
If "Yes", which ear
Left
Right
Both
Please rate the severity of the tinnitus between 1 and 5
*
Please Select
1
2
3
4
5
1 is mild, 5 is very bothersome
Have you used hearing aids or other hearing devices before?
*
Yes
No
Please rate your level of satisfaction between 1 and 5
Please Select
1
2
3
4
5
1 is very unsatisfied, 5 is very satisfied
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Other Details
Please check all conditions that apply
Family history of hearing loss
History of ear infections
History of ear surgery
Dizziness or vertigo
Trauma of the head or ears
Pain in the ears
Fluctuation of hearing
Earwax build up
Fullness or pressure in the ear
Chemotherapy
Radiation therapy
Diabetes
High blood pressure
Heart problems
Kidney problems
Migraines
Smoking
Auto-immune
Have you been exposed to extreme noise environments? Please check all that apply
Work
Hunting
Shooting
Factory noise
Power tools
Jet engines
Military
Other
Cerumen Management
During the appointment, your provider may need to perform cerumen, or earwax, removal before testing. Note: Cerumen removal may cause temporary discomfort or pain in the ear canal, bleeding, nausea, vomiting, dizziness/vertigo. Other associated risks include acute otitis externa, otitis media, and tympanic membrane perforation.
Do you take a blood thinner? (Coumadin, Plavix etc)
*
Yes
No
Do you consent for cerumen removal
*
Yes
No
Release of Records
I consent for Audicles Hearing Services to release my hearing healthcare records to the following persons or entities:
Submit
Should be Empty: