Hearing Program

Hearing Program

Hearing Aid Protection Screening Form
Today's Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Age
Date Of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Health Insurance Provider
Group #
ID #
Upload front of Insurance ID

Cancelof
Upload back of Insurance ID

Cancelof
Upload back of Driver's License

Cancelof
GunfireExplosivesLoud Industrial MachineryLoud SirensMechanical Banging
2. Years of Exposure*
YesNo
If Yes, how long:
YesNo
YesNo
6. Approximate date of last hearing test:

MonthDayYear
Date
Hearing Loss?Right earLeft earTinnitus/RingingDizzinessDifficult hearingIn QuietIn NoiseTelephone
8. How long have you noticed this difficulty?*
9. Primary reason for visit: *
10. How important is it for you to improve how you hear, understand, or communicate with others RIGHT NOW? *
(Rate 0 - Not at all important to 10 - Extremely Important)
YesNo
YesNo
If so, what brand/style?
Right ear/ Left Ear/ Both Ears
YesNo
If so, Date of Injury

MonthDayYear
Date
Explain:
YesNo
GradualSudden
YesNo
YesNo
leftrightboth
YesNo
Farm MachineryMusicHunting/ShootingMilitaryFactory NoisePower ToolsJet EnginesOther
YesNo
YesNo
If so, who?
YesNo
as a childas an adult
21. How much Nicotine used*
# of drinks per day/wk
How much Alcohol used*
# of drinks per day/wk
How much Caffeine used*
How much Aspirin used*
I am not ready for hearing aids at this time.I have been thinking that I might need hearing aids.I have started to seek information about hearing aids.I am ready to wear hearing aids if they are recommended.I currently wear hearing aids, but may need new ones or not ready for new ones.
I hereby consent to testing by the audiologist(s) of _______________________________. This consent also includes consent to take a medical history, perform diagnostic and/or audiologic testing, and when applicable: remove cerumen, and/or make ear impressions.

First Name Last Name Date
Signature
Should be Empty:

Hearing Program

Insurance Information