PAC Audiology Form

PAC Audiology Intake Form
Which of the following appointment types are you coming in for?*
Patient Information
Salutation*

Mrs.Ms.Mr.Dr.TheyNone
First Name*
Middle Name/Initial
Last Name*
Nickname
Sex*

MaleFemalePrefer not to answer
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Birthday*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.
Can we contact you via text or voice messages at this phone number?*

Text MessagesVoice MessagesBoth
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.
Referring Doctor
Referring Doctor's Phone Number
Please enter a valid phone number.
How did you hear about us?
Emergency Contact Name*
Relationship to Patient*
Emergency Phone Number*
Please enter a valid phone number.
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?

YesNo
Newborn hearing screen?

PassFailNo
Breathing difficulties (ventilation)?

YesNo
Admission to Intensive Care Unit (NICU)?

YesNo
Head, neck, or ear abnormalities?

YesNo
Skin tags or pits near the ears?

YesNo
Jaundice (high bilirubin)?

YesNo
If yes, for how long?
Head trauma/defects?

YesNo
Surgery?

YesNo
Diagnosis of neurologic condition?

YesNo
Vision problems?

YesNo
Kidney problems?

YesNo
Overnight hospital stays?

YesNo
Emergency room visits?

YesNo
Others
Pediatric - Communication and Development
Difficulties with pronunciation?

YesNo
If yes, please describe.
Language development concerns?

YesNo
If yes, please describe.
Difficulties listening/understanding?

YesNo
If yes, please describe.
Attention problems at school?

YesNo
If yes, please describe.
Other developmental delays?

YesNo
If yes, please describe.
Child frequently asks for things to be repeated?

YesNo
Child babble around 5-6 months of age?

YesNo
Child looks for sounds behind him/her at 13 months of age?

YesNo
Child began to imitate sounds?

YesNo
Child responds to sounds and voices?

YesNo
Child startled at loud noises?

YesNo
Child looks for the source of sounds?

YesNo
Hearing
Do you have hearing issues?

YesNo
Describe your hearing issues.
When did your problem begin?
How has your hearing changed since the onset?
Which ear do you hear well?

RightLeftI don't know
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?

YesSometimesNo
Do you need to ask people to repeat themselves?

YesSometimesNo
Is it hard to understand people in loud places?

YesSometimesNo
Do others say the TV is too loud?

YesSometimesNo
Have you noticed that people seem to mumble?

YesSometimesNo
Have you been told that you speak loudly?

YesSometimesNo
Tinnitus/Ringing (Noise in the ear)
Do you hear tinnitus/ringing in your ears(s) or head?

YesNo
Describe your sound issues.
When did your problem begin?
Where do you hear? Check all that apply.

RightLeftHead
Is it constant or periodic?

ConstantPeriodic
How has your sound changed since the onset?
Is it in time with your heart beat?

YesNo
Does it fluctuate in intensity?

YesNo
What makes it worse?
What makes it better?
Describe your previous treatments.
Did you have an MRI and/or CT scan?

YesNo
What is/was the conclusion of the medical exam?
Feeling of Pressure or Plugging (Fullness)
Do you have a feeling of pressure or plugging?

YesNo
When did the sensation begin?
Is it constant or periodic?

ConstantPeriodic
If periodic, how often?
Which ear? Check all that apply.

LeftRight
Any history of ear popping sensation?

YesNo
Dizziness
Do you have balance issues?

YesNo
Which of the following bests describes your symptoms? Check all that apply.

ImbalanceFalling more oftenWorld spinning around youYou feel as if YOU are spinning; the world is not spinningNauseaLightheadednessOther
How long do your symptoms last without stopping?

SecondsMinutesHoursDaysSymptoms are constant
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.

Head traumaMotor vehicle accidentUpper respiratory infectionChange in medicationFallVirus or infection, e.g., shingles, cold sores, COVID-19SurgeryStressful event or high stressOther
Have your symptoms improved/changed/stayed the same since they began?

ImprovedChangedStayed the same
If improved or changed, how so?
Does anything make your symptoms better?
Have you fallen in the past year?

YesNo
If yes, how many times?
If no, have you experienced “near falls” but you caught yourself?

YesNo
Are you afraid of falling?

YesNo
Are you veering/leaning while walking?

YesNo
If yes, which direction?

RightLeftBoth
Do you have neuropathy, numbness, or tingling in your feet or legs?

YesNo
Has your exercise decreased?

YesNo
If yes, approximately when?
Orthopedic injuries?

YesNo
If yes, please explain.
Do you have a history of migraines?

YesNo
If yes, when was your most recent migraine?
Do any of the following trigger your symptoms?

Increased stressSkipping a mealNot drinking enough waterChanges in weatherCertain foods
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.

HeadachesNeck painHearing loss in right earHearing loss in left earHearing loss in both earsFullness in right earFullness in left earFullness in both earsRinging in right earRinging in left earRinging both earsShimmers or sparkles in your visionSensitivity to lightSensitivity to soundSensitivity to smell
My dizziness is intense but only lasts for seconds or minutes.

YesNo
I get dizzy when I turn over in bed.

YesNo
I get short-lasting spinning dizziness that happens when I bend down to pick something up.

YesNo
I get short-lasting spinning dizziness that happens when I go from sitting to lying down.

YesNo
I can trigger my dizzy spells by placing my head in certain positions.

YesNo
I have had a single severe spell of spinning dizziness that lasted for hours to a day — for hours to days.

YesNo
After my big episode of dizziness, I could not walk for days without falling over.

YesNo
I had a spell of spinning dizziness that lasted for hours after I had a cold, virus, or flu.

YesNo
I had hearing loss in one ear at the same time I had the long episode of spinning dizziness.

YesNo
I feel dizzy all of the time.

YesNo
I am anxious most of the time.

YesNo
I am bothered by patterns, screens, e.g., supermarkets.

YesNo
My symptoms increase when I go from laying to sitting or sitting to standing.

YesNo
When I cough or sneeze, I get dizzy.

YesNo
I get dizzy when I strain to lift something heavy.

YesNo
When I speak, my voice sounds abnormally loud to me.

YesNo
My dizziness is provoked with head movements (up/down and/or right/left).

YesNo
My head is heavy like a bowling ball.

YesNo
I have a headache that is in or starts in the back of my head.

YesNo
When I sit up from lying down, or stand up from sitting, I experience a few seconds of dizziness.

YesNo
Is your blood sugar, blood pressure, and thyroid levels well controlled?

YesNo
Do you have any known eye/vision issues?

YesNo
If yes, please explain.
Do you have hearing loss?

YesNo
If yes, which ear?
Was your hearing loss sudden?

YesNo
Do you wear hearing aids?

YesNo
I am experiencing:

Ear painRingingDrainageFullnessNone
If yes, which ear?

RightLeftBoth
Are you pre/peri/post-menopausal?

YesNo
Did you have a hysterectomy?

YesNo
If yes, when?
Have you had any changes to your contraceptives?

YesNo
If yes, when?
Do you have a known hormonal imbalance?

YesNo
If yes, are you being treated for this issue?
Sound Sensitivity
Are you sensitive to certain sounds?

YesNo
Describe your sound sensitivity issues.
When did your problem begin?
Which ear is affected?

LeftRightI don't know
What makes it worse?
What makes it better?
Describe your previous treatments.
Did you have an MRI and/or CT scan?

YesNo
What is/was the conclusion of the medical exam?
Noise History
Do you have military experience?

YesNo
If yes, please provide your military occupational speciality and years.
Do you have a history of factory or construction jobs?

YesNo
If yes, please describe your jobs and years.
When in loud situations do you use ear protection?

YesNo
Have you done any of the following? Check all that apply.

Operated a chain sawDirt bikeFirearmsConcerts/loud musicLawn equipmentWood workingOther Loud Noises
Medical History
Do you have a history of ear infections?

YesNo
If yes, please describe your treatments.
Do you have a history of punctured/ruptured eardrum?

YesNo
If yes, please describe the year and what happened.
Do you still have your tonsils?

YesNo
In the past 90 days, have you had ear pain?

YesNo
In the past 90 days, have you had ear discharge?

YesNo
Do you have a family history of hearing loss?

YesNo
If yes, who had hearing loss?
Have you seen a physician about an ear problem in the last 6 months?

YesNo
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.

Ear surgeryEar malformationsAllergiesCleft palateKidney troubleDiabetes Type I/Type IIFragile bonesFainting spellsHigh blood pressureHead injuryMumpsScarlet feverMeaslesMeningitisCancerChronic conditionsER visitsOvernight hospitalizationMeniere's diseaseOtosclerosisCholesteatomaSudden hearing lossAttention disordersAnxiety disordersDepression disordersDexterity disordersSinusGERDLoose denturesJaw painMouth guardGrinding and clicking sensations in the jawOther
VA Compensation and Pension
VES Number (to be filled out by staff)*
First Name*
Last Initial*
Handed*

Right-handedLeft-handedBoth

Military Service Period 1
Military Occupational Speciality*
Military Service Period (Start)*

MonthDayYear
Date
Military Service Period (End)*

MonthDayYear
Date
Status*

ActiveReserved
What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.*

Section collapse
Kindly click and fill out each section if you have more than one enlistment.

Military Service Period 2
Military Occupational Speciality
Military Service Period (Start)

MonthDayYear
Date
Military Service Period (End)

MonthDayYear
Date
Status

ActiveReserved
What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.

Military Service Period 3
Military Occupational Speciality
Military Service Period (Start)

MonthDayYear
Date
Military Service Period (End)

MonthDayYear
Date
Status

ActiveReserved
What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.

Military Service Period 4
Military Occupational Speciality
Military Service Period (Start)

MonthDayYear
Date
Military Service Period (End)

MonthDayYear
Date
Status

ActiveReserved
What hearing protection did you use? Deployed to which countries? Had a combat experience in which countries? Please tell us more.

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