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  • Demographic Intake Form

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  • PERSONAL INFORMATION

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • ALTERNATE CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • ALTERNATE CONTACT INFORMATION #2

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Address 7807-109 St. NW, Edmonton, AB, T6G 1C6 Email info@acnahearing.com Phone 780.433.4441

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  • REFERRAL INFORMATION:

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  • LATE ARRIVAL POLICY ACKNOWLEDGMENT

  • To ensure fairness and quality of care for all clients, appointments will need to be rescheduled if a client arrives more than 15 minutes after their scheduled start time.
  • CONSENT FOR AI CLINICAL NOTE-TAKING

  • Address 7807-109 St. NW, Edmonton, AB, T6G 1C6 Email info@acnahearing.com Phone 780.433.4441

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  • Release Of Information

  • Audiology Clinic
    OF NORTHERN ALBERTA
  • 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.
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  • in Edmonton, Alberta

  • Address 7807 - 109 St. NW, Edmonton, AB, T6G 1C6
    Email info@acnahearing.com Phone 780.433.4441

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  • Medical Case History Form

  • Audiology Clinic
    OF NORTHERN ALBERTA
  • The purpose of this form is not only to provide us with information that will help determine the possible cause(s) of your hearing loss and appropriate next steps in treating your hearing loss, but also to help provide greater awareness around genetic, medical and lifestyle factors that increase the risk of developing hearing loss and potential accompanying conditions. The first section will help us understand the changes you are experiencing in your hearing.
  • While the primary cause of hearing loss is presbycusis, or age-related hearing loss, there are multiple other risk factors that cause changes in hearing, both directly as well as indirectly. This section will help us understand the possible causes of the changes in hearing that you are experiencing.
  • Our genetics increase our predisposition to hearing loss.

  • Significant noise exposure can be harmful to our hearing.

  • Some medications are ototoxic, or in other words, taking them may damage the structures of your inner ear causing hearing loss. When doctors prescribe these medications, this is often a calculated risk.
  • Address 7807 - 109 St. NW, Edmonton, AB, T6G 1C6
    Email info@acnahearing.com Phone 780.433.4441

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  • Medical Case History Form - cont.

  • There are multiple health conditions that may indirectly cause hearing loss, often due to changes in blood flow.
    Are you currently managing or have you experienced any of the following medical conditions?
  • There are several conditions that are often present along-side hearing loss, and they can have a significant impact on a person's social, emotional, physical and cognitive health. Some of these conditions are present because the physiological damage that caused hearing loss, also caused other conditions. Other times, living with hearing loss will result in these conditions.
  • While transient or occasional ear noise is experienced by everyone, constant phantom sounds are called tinnitus.
  • Untreated hearing loss may increase the risk of dementia.
  • Untreated hearing loss may increase the rates of depression, isolation and loneliness.
  • Untreated hearing loss may significantly increase your risk of falling.
  • There are several conditions that are important to be aware of as we pursue treatment of your hearing loss with hearing aids.
    Are you currently experiencing any of the following issues or using the following interventions?
  • Thank you for choosing the Audiology Clinic of Northern Alberta for your hearing health care needs! We look forward to working with you to help you achieve your communication goals. If there is anything else you like us to be aware of, please use the space below to let us know.
  • Address 7807 - 109 St. NW, Edmonton, AB, T6G 1C6
    Email info@acnahearing.com Phone 780.433.4441

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  • Hearing Handicap Inventory - Screener (Modified)

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  • Address 7807 - 109 St. NW, Edmonton, AB, T6G 1C6
    Email info@acnahearing.com Phone 780.433.4441

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