Patient Intake Form printable pdf download

Patient Intake Form

PATIENT INTAKE FORM

Client History

Today’s Date _______________

Last Name __________________________ First Name ________________________ MI ___

Address _________________________________ City __________________________ State _____

Zip Code ______________

Phone _________________ Alternate Phone ___________________ Email address _______________________

 Male  Female

 Married  Single Widow(er)

Date of Birth __________

Past/Present Occupation __________________________________________________

Accompanying Party ____________________________ Relationship to Patient _______________

Referring Physician Name _________________________________________________

How did you hear about us? _____________________________________________

Medical and Hearing Health History

Do you have any of the following:

 YES

 NO

Deformity of the ear?

 YES

 NO

Sudden or rapid hearing loss in the past 90 days?

 YES

 NO

Pain of discomfort in the ear?

 YES

 NO

Acute or recurring dizziness?

 YES

 NO

Previous ear infections?

 YES

 NO

Active drainage from the ear?

 YES

 NO

Have you ever found it necessary to have a doctor remove wax from your ear?

 BOTH  LEFT  RIGHT

In which ear do you feel you are hearing the worst?

Patient Intake Form