Accessibility Options

Contrast

Text

Visual

Statement

Report An Issue

Skip Navigation

724-933-3440 CALL: 724-933-3440

724-933-3440

Home
Care Team
Services
Insurance
Hearing Aids
Reviews
Why Choose Us
Videos
Patient Forms
- Complete Online
- Download or Print
Contact Us

Skip Main Content

Patient Registration Packet

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Middle Initial

Please complete this field.

Street Address

Please complete this field.

City

Please complete this field.

State

Please complete this field.

Zip Code

Please complete this field.

Home Phone

Please complete this field.

Cell Phone

Please complete this field.

Work Phone

Please complete this field.

Email Address

Please complete this field.

Would you prefer to be reached on your home, work, or cell phone?

Please select an option.

May we leave a message on your answering machine or voicemail?

Birth Date

Please complete this field.

Gender

Please complete this field.

Marital Status

Please complete this field.

Employed

Please select an option.

Occupation

Please complete this field.

Employer/School Name

Please complete this field.

Employer Address

Please complete this field.

Is Condition Accident Related:

Yes

No

Please select an option.

Date of Accident:

Please complete this field.

Is Condition Employment Related:

Yes

No

Please select an option.

Employment Incident Date:

Please complete this field.

Any Allergies:

Yes

No

Please select an option.

Please list your allergies:

Please complete this field.

Primary Care Physician:

Please complete this field.

PCP Phone:

Please complete this field.

Physician Who Referred You To Our Practice:

Please complete this field.

Referring Physician Phone:

Please complete this field.

Personal Emergency Contact:

Please complete this field.

Emergency Contact Phone:

Please complete this field.

PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

Parent/Guardian

Please select an option.

If other, please specify:

Please complete this field.

Last Name

Please complete this field.

First Name

Please complete this field.

Middle Initial

Please complete this field.

Street Address

Please complete this field.

City

Please complete this field.

Zip Code

Please complete this field.

Date of Birth

Please complete this field.

Gender

Please complete this field.

Marital Status

Please complete this field.

Employer or School Name

Please complete this field.

PRESENTING PROBLEM

What is your primary complaint about your ears or hearing?

Please complete this field.

If you have a hearing loss, what do you think caused it?

Please complete this field.

If you have a hearing loss, how long have you noticed this?

Please complete this field.

Which is your worse ear (if they are different):

Left

Right

Please select an option.

How important is it for you to improve how you hear, understand, or communicate with others?

Please select an option.

HISTORY

Have you had your hearing tested before?

Yes

No

Please select an option.

If yes, when and where?

Please complete this field.

Have you ever worn a hearing aid(s)?

Yes

No

Please select an option.

Any drainage from the ear within the past 90 days?

Yes

No

Please select an option.

Have you experienced any dizziness, balance problems, or falls?

Yes

No

Please select an option.

Have you had any pain/discomfort in your ears within the past 90 days?

Yes

No

Please select an option.

If yes, rate your pain on a scale of 0 (no pain) to 10 (worst pain possible):

Please complete this field.

Have you ever lost hearing suddenly?

Yes

No

Please select an option.

Have you received any medical or surgical treatment on your ears?

Yes

No

Please select an option.

Do you trouble with arthritis, stiffness, numbness in your fingers?

Yes

No

Please select an option.

Tinnitus Questions

Do you have any noises or ringing in your ears?

Yes

No

Please select an option.

Which ear?

Left

Right

Both

Please select an option.

If present, is it:

Constant

Intermittent

Please select an option.

When did you first notice it?

Please complete this field.

Noise Exposure Questions

Have you ever been exposed to loud noise?

Military

Work

Recreational

Please select an option.

If yes, describe the type of noise:

Please complete this field.

Did you use ear plugs/muffs?

Yes

No

Please select an option.

Family History

Is there a history of hearing loss in your immediate family?

Yes

No

Please select an option.

If yes, who:

Please complete this field.

MEDICAL HISTORY: Please check if you have experienced any of the following:

Infectious disease

Diabetes

Head injury

Kidney/renal problems

High blood pressure

Headache

Vision issues

Chronic sinus infections

Heart disease

Autoimmune

Stroke/TIA

Environmental allergies

Radiation/chemo

Cancer (please list type below)

Other (please explain):

Please complete this field.

Comments or questions for the audiologist:

Please complete this field.

HEARING HANDICAP INVENTORY

Instructions: Answer Yes, No, or Sometimes for each question. Do not skip a question if you avoid a situation because of a hearing problem. If you use a hearing aid, please answer according to the way you hear with the aid.

Does a hearing problem cause you to feel embarrassed when you meet new people?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you to feel frustrated when talking to members of your family?

Yes

No

Sometimes

Please select an option.

Do you have difficulty hearing when someone speaks in a whisper?

Yes

No

Sometimes

Please select an option.

Do you feel handicapped by a hearing problem?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you to attend events less often than you would like?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you to have arguments with family members?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you difficulty when listening to TV or radio?

Yes

No

Sometimes

Please select an option.

Do you feel that any difficulty with your hearing limits or hampers your personal or social life?

Yes

No

Sometimes

Please select an option.

Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

Yes

No

Sometimes

Please select an option.

LIST OF MEDICATIONS

Please include all prescription and over-the-counter medications (NAME OF MEDICATION, DOSAGE, FREQUENCY, PURPOSE OF MEDICATION)

Please complete this field.

Have you used a tobacco product at least once in the last 24 months?

Yes

No

Please select an option.

Thank you for subscribing!

You will receive important news and updates from our practice directly to your inbox.

Thanks!

Your form has been successfully submitted!

We will be in touch with you if additional information is needed.

Thanks!

CLOSE

Opt-out of using e-signatures?

Are you sure you want to opt-out of using e-signatures? You will be required to fill this form out again during your visit on a paper copy.

Download a copy of your signed form

Click the button below to download a PDF copy of your form

Close

Have a Question?

Talk to one of our experienced professionals or request an appointment in 4 incredibly easy steps

CALL: 724-933-3440

out of 5

Average rating: 4.93 stars out of 5

29 Patient Ratings

Connect with Us

(opens in new tab)(opens in new tab)(opens in new tab)(opens in new tab)(opens in new tab)

Subscribe to our Updates

Please enter a valid email.

POWERED BY

(opens in new tab)

Privacy Policy(opens in new tab)Data Security(opens in new tab)HIPAA(opens in new tab)Terms of Use(opens in new tab)