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Patient*:
Date of Birth:	Day Month Year
Spouse/ Companion:
Relationship:
Address:
City/State/Zip:
Phone*:
E-mail*:
Insurance:
Family Doctor:
Occupation:
Referred by:

Medical History
Have you seen a doctor for your hearing in the past six Months?	Yes No
Have you seen a doctor specializing in diseases of the ear?:	Yes No
Will this be your first hearing test?:	Yes No
Have you had ear surgery?:	Yes No
Do you take medicine every day?:	Yes No
Do you have High Blood Pressure?:	Yes No
Are you Diabetic?:	Yes No
Are you hypertensive?:	Yes No	Nervous:	Yes No
Do you have a heart condition?:	Yes No

Do you have any of the following:
Deformity of the ear?:	Yes No
Ear drainage?:	Yes No
Sudden or rapid hearing loss in the past 90 days?:	Yes No
Acute or recurring dizziness?:	Yes No
Has the hearing in one ear worsened in the past 90 days?:	Yes No
Do you ever have ear pain?:	Yes No
Have you ever had a doctor remove wax from your ears?:	Yes No
In which ear is your hearing the worst?:	Right Left
Do we have your permission to send hearing test results to your doctor?:	Yes No

Hearing History
Have you noticed that people seem to mumble?:	Yes No
Do you sometimes hear words but not understand them?:	Yes No
Do you find it difficult to hear in noisy places?:	Yes No
Do others complain you set the TV too loud?:	Yes No
Do you find it difficult to understand speech on the telephone?:	Yes No
Which ear do you use on the telephone?:	Right Left
Are you having trouble hearing	too much not enough
Do you want sounds to be	sharp and crisp mellow and comfortable
Have you ever worked around loud noises?:	Yes No
List 3 Areas you are having difficulty hearing:	1. 2. 3.
Is there any family history of hearing problems?:	Yes No
How many years have you had difficulty hearing?:
Do you have a hearing aid?:	Yes No	Brand:
When selecting a hearing system, I am most concerned with:	as a small and inconspicuous as possible the latest in technology follow-up service from the office price
Any Comments: