Patient Intake Form
Name
First Name
Last Name
Complete Mailing Address
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Date Of Birth (MM/DD/YYYY)
*
Name Of Caretaker (If Applicable)
Insurance Provider
Do you ask people to repeat?
Yes
No
Sometimes
Do you hear words but don’t understand?
Yes
No
Sometimes
Do you turn the TV up louder than normal?
Yes
No
Sometimes
Are you looking for a new hearing device?
Yes
No
What Type?
Do you stay out of social environments because of your hearing loss?
Yes
No
Sometimes
What is your worst situation for hearing?
Have you ever had your hearing tested?
Yes
No
Last Test Date
Do you wear a hearing aid?
Yes
No
When were you last fit?
Make
Model
Style
How long have you had a hearing problem?
How long have you worn hearing aids?
Do you go to an ENT for Medical Ear related issues?
Yes
No
Dizziness (last 90 days)
Yes
No
Sometimes
Earwax Issues?
Yes
No
Sometimes
Recent Sudden or rapidly progressing hearing loss (last 90 days?)
Yes
No
Recent Ear Pain?
Yes
No
Sometimes
Ear surgery?
Yes
No
Details of Ear Surgery (If applicable)
Hearing loss in one ear only?
Yes
No
Anything else you want the Hearing Specialist to know
Submit
Should be Empty: