Patient Intake Form

Patient Intake Form
Your Personal Details
Name*

PrefixFirst NameLast Name
I am*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Referred by
Reason for first visit
Equipment/Service needed
Your Family Doctor
Family Dr. Name
Family Dr. Phone

Area CodePhone Number
Family Dr. Fax

Area CodePhone Number
Emergency Contact Details
Name
Phone Number

Area CodePhone Number
Your Health History
Have You Had Your Hearing Tested Before?*

YesNo
Have You Worn a Hearing Aid Before?*

YesNo
Have Family or Friends Commented on Your Hearing?*

YesNo
Type a question

DiabetesHigh Blood PressureHeart ProblemsKidney ProblemsPain in Your EarsChemotherapyRinging or BuzzingIV AntibioticsMigrainesFamily History of Hearing LossHistory of Ear InfectionsHistory of Noise ExposureHistory of Ear SurgeryDizzinessEar SurgeryHearing or Ear TraumaHearing FluctuationRadiation Therapy
Type of Noise Exposure

Farm EquipmentHunting/ShootingMusicFactory NoiseWorkPower ToolsJet EnginesHobbiesMilitaryOther
Do You Take a Blood Thinner? (Coumadin, Plavix etc.)

YesNo
A signature below acknowledges that you have received a copy of the HIPAA Privacy PRactices of this office.
I consent for you to release my hearing healthcare records (or my child's) to the following people:
Signature*

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Date

MonthDayYear
Should be Empty: