Patient Registration Packet
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE
PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
PRESENTING PROBLEM
PRESENTING PROBLEM
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
HISTORY
HISTORY
Please complete this field.
Please complete this field.
Tinnitus Questions
Please complete this field.
Noise Exposure Questions
Please complete this field.
Family History
Please complete this field.
MEDICAL HISTORY: Please check if you have experienced any of the following:
MEDICAL HISTORY: Please check if you have experienced any of the following:
Please complete this field.
Please complete this field.
HEARING HANDICAP INVENTORY
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.
LIST OF MEDICATIONS
LIST OF MEDICATIONS
Please complete this field.