THE HEARING SOLUTION - New Patient History Form

New Patient History Form
Full Name*

PrefixFirst NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Gender*
Self Described/Preferred Pronouns
ex. they/them
Cell Phone

Area CodePhone Number
Type a question

Okay to text
Home Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry
E-mail Address
Marital Status*

MarriedWidowedDivorcedSingle
Spouse's Name
Insurance Information
Primary Care Physician*
Occupation (past/present)
Emergency Contact
How did you hear about us?
Health History
What is your primary reason for coming in today?*
When/where was your last hearing test?
How long ago did you notice a change in your hearing?

Rows	Yes	No
Do you have a better hearing ear?
Have you experienced a sudden/progressive hearing loss in the last 90 days?
Have you had any ear surgeries?
Do you suffer from ear pain?
Do you have pressure or fullness in your ears?
Have you had chronic ear infections?
Do you have drainage from your ears?
Do you have a history of head trauma?
Do you have a family history of hearing loss?
Do you notice ringing/buzzing/tinnitus in your ears?
Do you have a history of dizziness/vertigo?
Do you have a history of excessive noise exposure?
Do you have a history of wax build up?

Please list any current medications:
Hearing Health History
What environments or situations would you like to hear better in?
Make a list of the loved ones you communicate with most often:

Please rate your present hearing ability:

	1	2	3	4	5	6	7	8	9	10

1 is Perfect hearing, 10 is Severe hearing loss

What is the main reason you would like to improve your hearing and communication ability?

Please rate how motivated you are to use hearing aids:

	1	2	3	4	5	6	7	8	9	10

1 is Not Motivated, 10 is Very Motivated

Are you interested in any of the following hearing aid technologies?

RechargeabilityiPhone connectivityAndroid connectivityTelevision streamingAt-home remote programming through video chatTelecoil and loop system technology

How much difficulty do you have hearing in the following situations?

Rows	No Difficulty	Slight Difficulty	Moderate Difficulty	Very much difficulty	Not Relevant
One on one conversations
Conversations in small groups
Conversations in large groups
Outdoors
Concerts/Theaters
Place of worship/lecture halls
Watching TV
In a car
Landline Phone
Cell Phone
Restaurants

Do you currently use a hearing aid?
List any problems you are having with the hearing aid(s)
How would you prefer your educational materials?
Notice of Privacy Practices and Right to Bill
Please review and check the following boxes:

I give permission to this practice to release information, verbal or written, contained in my medical record and other related information to my insurance company, healthcare providers, assignees and/or beneficiaries and all other related persons.I acknowledge that I have had the opportunity to review a copy of The Hearing Solution’s privacy notice. (Available to view on our website and in the office)I hereby authorize all benefits for charges of examination and/or treatments requested to be paid to The Hearing Solution. Verification of insurance coverage obtained over the phone does not guarantee payment. I have read this statement and accept full financial responsibility for all medical charges incurred by my dependents or me for services rendered by The Hearing Solution.I allow the following individuals (eg. spouse/family members/caregivers) to be allowed access to my information regarding my hearing and ongoing treatments for the duration of my care, unless The Hearing Solution is notified otherwise:I give permission for The Hearing Solution to text for appointment reminders and general communication.If I leave a google/yelp review, I give The Hearing Solution permission to use my review on the website or for other marketing purposes.
Signature
Date

MonthDayYear
*

I have read the above form and acknowledge receipt of all information
Should be Empty:

New Patient History Form

Health History

Hearing Health History

Notice of Privacy Practices and Right to Bill