[ACNA] ADULT Intake Form

Demographic Intake Form
PERSONAL INFORMATION
Date

MonthDayYear
Date
Name*
Address*
City*
Province*
Postal Code*
DO NOT send print mailings
Date of birth:

MonthDayYear
Date
Personal Health Number:*
Email:
example@example.com
Mobile Phone:
Do NOT textIt’s OK to email me messages such as appointment reminders, newsletters and special offers.
Home Phone:
Work Phone:
ALTERNATE CONTACT INFORMATION
Name:
Address:
City:
Province:
Postal Code:
Is primary contactUse alternate contact for billing
Relationship to patient:
Email:
example@example.com
Mobile Phone:
Please enter a valid phone number.
It’s OK to email me messages such as appointment reminders, newsletters and special offers
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
ALTERNATE CONTACT INFORMATION #2
Name
Address
City
Province
Postal Code
Use alternate contact for billing
Relationship to patient
Email:
example@example.com
Mobile Phone:
It’s OK to email me messages such as appointment reminders, newsletters and special offers
Home Phone:
Work Phone
THIRD PARTY INFORMATION:
Workers' Compensation Board - Alberta
Claim Number:
Veteran's' Affairs Canada
Claim Number:
First Canadian Health (NIHB)
Identification Number:
Other:
Program ID Number:
REFERRAL INFORMATION:
Who referred you, or how did you find out about us:*
Primary Care Physician: *
Clinic Name:
I understand my hearing test results will be available
in two weeks please initial I need results by Date
Release Of Information
I,Name* understand that Audiology Clinic of Northern Alberta will only use personal information that I provide to serve me with the services that I request. Audiology Clinic of Northern Alberta may share my personal information only with organizations that participate in my care including but not limited to my physician, the manufacturer of my products, and any third party participating in the payment of my products and/or services.

I also understand that Audiology Clinic of Northern Alberta abides by Alberta’s privacy laws and regulations and has a privacy policy that I can request.

I therefore give consent to Audiology Clinic of Northern Alberta to responsibly use my personal information to contact me and share with others only as required to serve my needs. Signed on Date in Edmonton, Alberta.

Signed Name: Signature* Printed Name: First Name* Last Name*
I am unable to digitally sign this document due to current circumstances,
Medical Case History Form
Name*
Date

MonthDayYear
Date
There are several genetic, medical and lifestyle factors that increase the risk of developing hearing loss and tinnitus. This hearing loss, when left untreated, can also lead to a host of other comorbid medical conditions. Please complete this form in its entirety for review with your hearing healthcare provider.
1. Direct Risk Factors Hearing Loss and Tinnitus
Age the primary risk factor for hearing loss and tinnitus is your age. Indicate which age category you are in:

Between the age of 60-70 y/o. (~50% of people have significant hearing loss)Between the age of 70-80 y/o. (~66% of people have significant hearing loss)Over the age of 80 y/o. (+80% of people have significant hearing loss)
*Hearing Loss that results from age can begin in a person’s 40’s and 50’s
Genetics Our genetics increase our predisposition to developing hearing loss and tinnitus. Please describe your family history of hearing loss and tinnitus:
Noise Exposure Exposure to noise is detrimental to the ear and impacts our ability to process words. Check the situations below where you have been exposed to loud noises:

WorkConcertsWeddingLawn MowerFire ArmsSporting EventsMotorized VehiclesPower ToolsFireworksFire AlarmsMovie TheatersRestaurantsSmartphone / Headphones
Medications Pharmaceuticals can affect the ear and result in hearing loss and tinnitus. Please check the medications you have been exposed to:*

Cancer Treatment (i.e. Chemotherapy)Fluoroquinolones (i.e. Ciproflaxin / ‘Cipro’)Aminoglycoside Antibiotics (i.e. Azythromyocin / ‘Z-Pac’,Streptomycin, and medication that ends with ‘mycin’)Long-term use of Asprin, Naproxen (Aleve),Ibuprofen (Advil) and Acetaminophen (Tylenol)
Medical Case History Form - cont.
2. Indirect Risk Factors

e.g. other Medical Conditions That Can Increase the Risk of Hearing Loss and Tinnitus Many common health conditions significantly increase the risk of hearing loss and tinnitus. Please check all of the medical conditions you are currently managing / concerned about as they significantly increase your risk of hearing loss and tinnitus:
Cardiovascular Disease (i.e. hypertension, arrhythmiaand / or Hx of stroke, heart valve complications or heart attack)Diabetes or Pre-DiabetesKidney Disease (i.e. Chronic Kidney Disease, Kidney Infections, Kidney Stones, Cysts or Cancer)Thyroid Disease (i.e. Hyper- or Hypothyroidism, Cancer, etc.)Autoimmune Disease (i.e. Rheumatoid Arthritis, Lupus)History of SmokingHead Trauma (i.e. Hx of concussions or unconsciousness)
3. Comorbid Medical Conditions
Damage to the ear that causes hearing loss and tinnitus can have a significant impact on a person’s social, emotional, physical and cognitive health. Please check all of the comorbid conditions that you are dealing with:
Difficulty Hearing (Please check all that apply)

Missing parts of what other people are saying to you (i.e. you sometimes miss the beginning or the end of a conversation)Difficulty following a conversation in background noiseMy family / friends tell me I have a problem hearing /listeningI often need the TV louder than othersPeople around me tend to mumble a lot!Difficulty hearing on the phoneDifficulty hearing at church / large gatherings
How long have you been experiencing these difficulties with hearing?

Past 90 days1 - 3 Years4 - 7 Years+10 Years
Medical Case History Form - cont.
Tinnitus (Phantom sounds in the ears and/or head occur in over 90% of people living with hearing loss)
I have been experiencing tinnitus for Enter Monthsmonths or Enter Years years.
My Tinnitus is present in:

Both EarsLeft EarsRight Ear
My Tinnitus is:

ConstantOnly Noticeable In QuietIntermittent (comes and goes)Pulsates
On a scale of 1-10 (1 = ‘What tinnitus?’, 10 = ‘MAKE IT STOP!’) I would rate the annoyance of my tinnitus as a:

Cognitive Decline (Untreated hearing loss and tinnitus can increase the risk of dementia by 200-500%)

	Yes	No
Are you concerned about memory loss or developing dementia?
Do you have a family history of cognitive decline or dementia?

Mental Health Concerns (Untreated hearing loss and tinnitus increase the rates of depression, isolation and loneliness)

	Yes	No
Do you have feelings of sadness or depression?
Are you feeling ‘on edge’ or stressed lately?
Are you feeling lonely?
Do you find yourself isolating from others (i.e. saying ‘no’ to invitations from others)?

Falls (Untreated hearing loss and tinnitus can significantly increase your risk of a traumatic fall)

	Yes	No
Have you fallen in the past 12 months?
Are you concerned about falling?

Hearing Handicap Inventory - Screener (Modified)
INSTRUCTIONS: The purpose of this questionnaire is to identify the problems your hearing loss may (or may not) becausing you. Select Yes, Sometimes or No for each question. Please do not skip a question if you avoid a situation becauseof a hearing problem.

	Yes	Sometimes	No
1. Does your hearing problem cause you to feel embarrassed when meeting new people?
2. Does your hearing problem cause you to feel frustrated whentalking to members of your family?
3. Do you have difficulty hearing when someone speaks in a whisper?
4. Do you feel that your hearing problem affects your quality of life?
5. Does your hearing problem cause you difficulty when visiting friends, relatives or neighbors?
6. Does your hearing problem cause you to attend meetings or religious services less often than you would like?
7. Does your hearing problem cause you to have arguments with family members?
8. Does your hearing problem cause you difficulty when listening to the TV or radio at a volume preferred by other listeners
9. Do you feel that the difficulty with your hearing limits or hampers your personal or social life?
10. Does your hearing problem cause you difficulty when in a restaurant with relatives or friends?

Should be Empty:

Demographic Intake Form

PERSONAL INFORMATION

ALTERNATE CONTACT INFORMATION

ALTERNATE CONTACT INFORMATION #2

THIRD PARTY INFORMATION:

REFERRAL INFORMATION:

Release Of Information

Medical Case History Form

Hearing Handicap Inventory - Screener (Modified)