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Patient Registration Packet

Patient First Name

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Patient Last Name

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Middle Initial

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Street Address

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City

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State

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Zip Code

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Home Phone

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Cell Phone

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Work Phone

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Email Address

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

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

Birth Date

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Gender

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Marital Status

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Employed

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Occupation

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Employer/School Name

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Employer Address

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Is Condition Accident Related:

Yes

No

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Date of Accident:

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Is Condition Employment Related:

Yes

No

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Employment Incident Date:

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Any Allergies:

Yes

No

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Please list your allergies:

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Primary Care Physician:

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PCP Phone:

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Physician Who Referred You To Our Practice:

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Referring Physician Phone:

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Personal Emergency Contact:

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Emergency Contact Phone:

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PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

Parent/Guardian

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If other, please specify:

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Last Name

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First Name

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Middle Initial

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Street Address

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City

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Zip Code

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Date of Birth

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Gender

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Marital Status

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Employer or School Name

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PRESENTING PROBLEM

What is your primary complaint about your ears or hearing?

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

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

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

Left

Right

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

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HISTORY

Have you had your hearing tested before?

Yes

No

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If yes, when and where?

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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

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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):

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Have you ever lost hearing suddenly?

Yes

No

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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

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If present, is it:

Constant

Intermittent

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When did you first notice it?

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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:

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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:

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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):

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Comments or questions for the audiologist:

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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.

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