For all of our new patients please fill out the following form and we will contact you as soon as possible.
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Patient*:
Date of Birth:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31Day  Jan Feb March April May June July Aug Sept Oct Nov DecMonth Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 EarlierYear
Spouse/ Companion:
Relationship:
Address:
City/State/Zip:
Phone*:
E-mail*:
Social Security Number:
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?:	RightLeft
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 muchnot enough
Do you want sounds to be	sharp and crispmellow 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:

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