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Patient Registration Packet

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Is Condition Accident Related:
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Is Condition Employment Related:
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Any Allergies:
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PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE


PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

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PRESENTING PROBLEM


PRESENTING PROBLEM

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


HISTORY

Have you had your hearing tested before?
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Have you ever worn a hearing aid(s)?
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Any drainage from the ear within the past 90 days?
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Have you experienced any dizziness, balance problems, or falls?
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Have you had any pain/discomfort in your ears within the past 90 days?
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Have you ever lost hearing suddenly?
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Have you received any medical or surgical treatment on your ears?
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Do you trouble with arthritis, stiffness, numbness in your fingers?
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Tinnitus Questions
Do you have any noises or ringing in your ears?
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Which ear?
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If present, is it:
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Noise Exposure Questions
Have you ever been exposed to loud noise?
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Did you use ear plugs/muffs?
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Family History
Is there a history of hearing loss in your immediate family?
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MEDICAL HISTORY: Please check if you have experienced any of the following:


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

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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.
Does a hearing problem cause you to feel embarrassed when you meet new people?
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Does a hearing problem cause you to feel frustrated when talking to members of your family?
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Do you have difficulty hearing when someone speaks in a whisper?
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Do you feel handicapped by a hearing problem?
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Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?
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Does a hearing problem cause you to attend events less often than you would like?
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Does a hearing problem cause you to have arguments with family members?
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Does a hearing problem cause you difficulty when listening to TV or radio?
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Do you feel that any difficulty with your hearing limits or hampers your personal or social life?
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Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?
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LIST OF MEDICATIONS


LIST OF MEDICATIONS

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