PAC Audiology Form

PAC Audiology Intake Form
Which of the following appointment types are you coming in for?
Patient Information
Salutation
First Name
Middle Name/Initial
Last Name
Nickname
Sex
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Birthday

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we contact you via text or voice messages at this phone number?
Email Address
example@example.com
Employment/Education Details
Employer
Occupation
School Name
School Grade
Referral and Contact Information
Primary Care Doctor
Primary Care Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Doctor
Referring Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Emergency Contact Name
Relationship to Patient
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Email Address
example@example.com
Pediatric - At Birth
Length of pregnancy?
Birth weight?
APGAR Score
List of medications/drugs used during pregnancy (including alcohol)
Please describe any unusual aspects of the pregnancy.
Complicated delivery?
Newborn hearing screen?
Breathing difficulties (ventilation)?
Admission to Intensive Care Unit (NICU)?
Head, neck, or ear abnormalities?
Skin tags or pits near the ears?
Jaundice (high bilirubin)?
If yes, for how long?
Head trauma/defects?
Surgery?
Diagnosis of neurologic condition?
Vision problems?
Kidney problems?
Overnight hospital stays?
Emergency room visits?
Others
Pediatric - Communication and Development
Difficulties with pronunciation?
If yes, please describe.
Language development concerns?
If yes, please describe.
Difficulties listening/understanding?
If yes, please describe.
Attention problems at school?
If yes, please describe.
Other developmental delays?
If yes, please describe.
Child frequently asks for things to be repeated?
Child babble around 5-6 months of age?
Child looks for sounds behind him/her at 13 months of age?
Child began to imitate sounds?
Child responds to sounds and voices?
Child startled at loud noises?
Child looks for the source of sounds?
Hearing
Do you have hearing issues?
Describe your hearing issues.
When did your problem begin?
How has your hearing changed since the onset?
Which ear do you hear well?
Date of your last hearing exam?

MonthDayYear
Date
Where did you have the exam?
Do you avoid social events because it is hard to hear?
Do you need to ask people to repeat themselves?
Is it hard to understand people in loud places?
Do others say the TV is too loud?
Have you noticed that people seem to mumble?
Have you been told that you speak loudly?
Tinnitus/Ringing (Noise in the ear)
Do you hear tinnitus/ringing in your ears(s) or head?
Describe your sound issues.
When did your problem begin?
Where do you hear? Check all that apply.
Is it constant or periodic?
How has your sound changed since the onset?
Is it in time with your heart beat?
Does it fluctuate in intensity?
What makes it worse?
What makes it better?
Describe your previous treatments.
Did you have an MRI and/or CT scan?
What is/was the conclusion of the medical exam?
Feeling of Pressure or Plugging (Fullness)
Do you have a feeling of pressure or plugging?
When did the sensation begin?
Is it constant or periodic?
If periodic, how often?
Which ear? Check all that apply.
Any history of ear popping sensation?
Dizziness
Do you have balance issues?
Which of the following bests describes your symptoms? Check all that apply.

Other
How long do your symptoms last without stopping?
How many times per day/week/month/year do you have an episode?
Did any of the following occur prior to your symptom onset? Check all that apply.

Other
Have your symptoms improved/changed/stayed the same since they began?
If improved or changed, how so?
Does anything make your symptoms better?
Have you fallen in the past year?
If yes, how many times?
If no, have you experienced “near falls” but you caught yourself?
Are you afraid of falling?
Are you veering/leaning while walking?
If yes, which direction?
Do you have neuropathy, numbness, or tingling in your feet or legs?
Has your exercise decreased?
If yes, approximately when?
Orthopedic injuries?
If yes, please explain.
Do you have a history of migraines?
If yes, when was your most recent migraine?
Do any of the following trigger your symptoms?
Describe certain foods that trigger your symptoms.
Do any of the following accompany or occur immediately prior to an episode of your symptoms? Check all that apply.
My dizziness is intense but only lasts for seconds or minutes.
I get dizzy when I turn over in bed.
I get short-lasting spinning dizziness that happens when I bend down to pick something up.
I get short-lasting spinning dizziness that happens when I go from sitting to lying down.
I can trigger my dizzy spells by placing my head in certain positions.
I have had a single severe spell of spinning dizziness that lasted for hours to a day — for hours to days.
After my big episode of dizziness, I could not walk for days without falling over.
I had a spell of spinning dizziness that lasted for hours after I had a cold, virus, or flu.
I had hearing loss in one ear at the same time I had the long episode of spinning dizziness.
I feel dizzy all of the time.
I am anxious most of the time.
I am bothered by patterns, screens, e.g., supermarkets.
My symptoms increase when I go from laying to sitting or sitting to standing.
When I cough or sneeze, I get dizzy.
I get dizzy when I strain to lift something heavy.
When I speak, my voice sounds abnormally loud to me.
My dizziness is provoked with head movements (up/down and/or right/left).
My head is heavy like a bowling ball.
I have a headache that is in or starts in the back of my head.
When I sit up from lying down, or stand up from sitting, I experience a few seconds of dizziness.
Is your blood sugar, blood pressure, and thyroid levels well controlled?
Do you have any known eye/vision issues?
If yes, please explain.
Do you have hearing loss?
If yes, which ear?
Was your hearing loss sudden?
Do you wear hearing aids?
I am experiencing:
If yes, which ear?
Are you pre/peri/post-menopausal?
Did you have a hysterectomy?
If yes, when?
Have you had any changes to your contraceptives?
If yes, when?
Do you have a known hormonal imbalance?
If yes, are you being treated for this issue?
Sound Sensitivity
Are you sensitive to certain sounds?
Describe your sound sensitivity issues.
When did your problem begin?
Which ear is affected?
What makes it worse?
What makes it better?
Describe your previous treatments.
Did you have an MRI and/or CT scan?
What is/was the conclusion of the medical exam?
Noise History
Do you have military experience?
If yes, please provide your military occupational speciality and years.
Do you have a history of factory or construction jobs?
If yes, please describe your jobs and years.
When in loud situations do you use ear protection?
Have you done any of the following? Check all that apply.

Other Loud Noises
Medical History
Do you have a history of ear infections?
If yes, please describe your treatments.
Do you have a history of punctured/ruptured eardrum?
If yes, please describe the year and what happened.
Do you still have your tonsils?
In the past 90 days, have you had ear pain?
In the past 90 days, have you had ear discharge?
Do you have a family history of hearing loss?
If yes, who had hearing loss?
Have you seen a physician about an ear problem in the last 6 months?
List Medications (you can provide a list of medications at your appointment)
Please choose any of the following physical conditions you have had. Check all that apply.

Other
VA Compensation and Pension
VES Number (to be filled out by staff)
First Name
Last Initial
Handed
- Military Occupational Speciality
- Military Service Period (Start)
  
  MonthDayYear
  Date
- Military Service Period (End)
  
  MonthDayYear
  Date
- Status
- What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.
- Kindly click and fill out each section if you have more than one enlistment.
- Military Occupational Speciality
- Military Service Period (Start)
  
  MonthDayYear
  Date
- Military Service Period (End)
  
  MonthDayYear
  Date
- Status
- What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.
- Military Occupational Speciality
- Military Service Period (Start)
  
  MonthDayYear
  Date
- Military Service Period (End)
  
  MonthDayYear
  Date
- Status
- What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.
- Military Occupational Speciality
- Military Service Period (Start)
  
  MonthDayYear
  Date
- Military Service Period (End)
  
  MonthDayYear
  Date
- Status
- What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.
- What kind of noises were you exposed to PRIOR to military service?
  
  Other noise
- What kind of noises were you exposed to DURING to military service?
  
  Other noise
- What kind of noises were you exposed to AFTER to military service?
  
  Other noise
- Jobs prior to military service
- Jobs after military service
- Does your hearing loss impact ordinary conditions of daily life, including ability to work?
- If yes, describe the impact.
- Do you hear tinnitus/ringing?
- If yes, please specify date and circumstances of onset of tinnitus.
- What does it sound like?
- Is it constant or periodic?
- Is it improved, worse, or the same?
- Does your tinnitus impact ordinary conditions of daily life, including ability to work?
- If yes, please describe the impact.
- Please write any ear-related medical issues.
- Email Sender
- Email Reply
- Should be Empty:

PAC Audiology Intake Form

Patient Information

Employment/Education Details

Referral and Contact Information

Pediatric - At Birth

Pediatric - Communication and Development

Hearing

Tinnitus/Ringing (Noise in the ear)

Feeling of Pressure or Plugging (Fullness)

Dizziness

Sound Sensitivity

Noise History

Medical History

VA Compensation and Pension