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: