[ACNA] Adult Intake Form

  • Personal Information

  • Today's Date
     - -
  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • It’s OK to email me messages such as appointment reminders, newsletters and special offers.*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Alternate Contact Information #1

    (Optional)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Alternate Contact Information #2

    (Optional)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Third Party Information

    Please fill if applies

  • Referral Information

  • I understand my hearing test results will be available
    in two weeks* I need my test results by:*

  • Release of Information

  • I,   *  , understand that Audiology Clinic of Northern Alberta will only use personal information that I provide, to serve me with the services that I request. Audiology Clinic of Northern Alberta may share my personal information only with organizations that participate in my care including but not limited to my physician, the manufacturer of my products, and any third party participating in the payment of my products and/or services.

    I also understand that Audiology Clinic of Northern Alberta abides by Alberta’s privacy laws and regulations and has a privacy policy that I can request.
    I therefore give consent to Audiology Clinic of Northern Alberta to responsibly use my personal information to contact me and share with others only as required to serve my needs.

    Signed* day of*  , 20* :

  • Case History

  • Have you had your hearing tested before?*
  • Do you have hearing loss?*
  • If yes, which ear(s)?*
  • How was the onset of your hearing loss?*
  • Which ear do you use to talk on the phone?*
  • Does anyone in your family have a hearing loss?*
  • Have you ever had an ear surgery?*
  • Do you take blood thinners?*
  • Do you use a pacemaker?*
  • Have you seen a physician recently?*
  • Do you have a history of ear infections?*
  • Do you suffer from:*
  • Do you have a history of noise exposure?*
  • Do you have tinnitus?*
  • Do you have increased sensitivity to certain sounds?*
  • Do you suffer from:*
  • Have you ever had a head injury?*
  • Do you currently wear hearing aids?*
  • If you don’t currently wear hearing aids, are you interested in obtaining hearing aids to treat permanent hearing loss?*

  • Screener

  • The purpose of this questionnaire is to identify the problems your hearing loss may (or may not) be causing you. Select Yes, Sometimes or No for each question. Please do not skip a question if you avoid a situation because of a hearing problem

  • E-1. Does your hearing problem cause you to feel embarrassed when meeting new people?*
  • E-2. Does a hearing problem cause you to feel frustrated when talking to members of your family?*
  • S-1. Does a hearing problem cause you difficulty hearing/understanding co-workers, clients or customers*
  • E-3. Do you feel handicapped by a hearing problem?*
  • S-2. Does a hearing problem cause you difficulty when visiting friends, relatives or neighbors?*
  • S-3. Does a hearing problem cause you difficulty in the movies or theater?*
  • E-4. Does a hearing problem cause you to have arguments with family members?*
  • E-5. Do you feel that any difficulty with your hearing limits or hampers your personal or social life?*
  • S-5. Does a hearing problem cause you difficulty when at a restaurant with relatives or friends?*
  • Should be Empty: