THE HEARING SOLUTION - New Patient Tinnitus Form

New Patient History Form
Full Name*

PrefixFirst NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Gender*
Preferred Pronouns
ex. they/them
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry
E-mail Address
How would you prefer we contact you?
MarriedWidowedDivorcedSingle
Spouse's Name
Primary Care Physician
Occupation (past/present)
How did you hear about us?
Insurance
ID#
Health History
What is your primary reason for coming in today?
When/where was your last hearing test?

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 excessive noise exposure?

Please list any current medications:
Tinnitus and Hearing History

Please answer the following groups of questions:

Have you ever:

Rows	Yes	No
Had any noisy jobs?
Had any noisy hobbies or home activities?
Used solvents, thinners or alcohol based cleaners?

Do you:

Rows	Yes	No
Have loose dentures, jaw pain or grinding/clicking in your jaw?
Regularly take aspirin or other pain killers?
Have any difficulties hearing when there is background noise?
Have any difficulties hearing the TV?
Have any difficulties hearing on the telephone?
Wear ear protection/earplugs?
Find certain sounds unpleasant, uncomfortable or too loud?

Effects of your tinnitus:
Over the past week, what percentage of the time were you aware of your tinnitus?
What percentage of the time was it disturbing?
Describe the sound of your tinnitus (hissing, ringing, buzzing, etc.)
In which situations do you notice your tinnitus the most?
In which ear do you hear your tinnitus?
Is it worse in one ear?
Is your tinnitus:

Rows	Yes	No
Does your tinnitus fluctuate in loudness?
Do you find exposure to moderately loud sounds makes your tinnitus worse?
Does your tinnitus affect your sleep?
Have you tried any medications in the past for your tinnitus?
Are you pending any legal action?

What makes your tinnitus worse?
What makes your tinnitus better?
How has tinnitus affected your work life?
How has tinnitus affected your home life?
How has tinnitus affected your social life?
Tinnitus History
When did you first become aware of your tinnitus and what do you consider to have first started your tinnitus?
When did your tinnitus first become disturbing? Any specific situation?
Who have you consulted about your tinnitus?
What have you been told about your tinnitus?
NoneTRTHearing AidCounselingMaskerMusic TherapyOther
How successful were these treatments?
Please rank the auditory problems you experience:

Hearing Difficulties:

	1	2	3	4	5	6	7	8	9	10

1 is Perfect Hearing, 10 is Severe Hearing Loss

Tinnitus:

	1	2	3	4	5	6	7	8	9	10

1 is Not Very Troublesome, 10 is Very Troublesome

Sensitivity to Loud Sounds:

	1	2	3	4	5	6	7	8	9	10

1 is Not Very Troublesome, 10 is Very Troublesome

Notice of Privacy Practices and Right to Bill
I allow for voice messages from this practice to be left on any provided phone number.I allow for text messages from this practice to be sent to my mobile number.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.On occasion, The Hearing Solution sends out newsletters or birthday cards. I allow for The Hearing Solution to contact me by mail or e-mail for promotional reasons.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:
(eg. spouse/caregivers/family members)
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I have read the above form and acknowledge receipt of all information
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New Patient History Form

Health History

Tinnitus and Hearing History

Notice of Privacy Practices and Right to Bill