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?

Employed

Please select an option.

Is Condition Accident Related:

Yes

No

Please select an option.

Is Condition Employment Related:

Yes

No

Please select an option.

Any Allergies:

Yes

No

Please select an option.

Please list your allergies:

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.

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.

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.

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.

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.

Noise Exposure Questions

Have you ever been exposed to loud noise?

Military

Work

Recreational

Please select an option.

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.

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.

Patient Registration Packet

PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

PRESENTING PROBLEM

PRESENTING PROBLEM

HISTORY

HISTORY

Tinnitus Questions

Noise Exposure Questions

Family History

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

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

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