Patient Intake Form (Page 2 of 2) in pdf

Medical and Hearing Health History (continued)

 YES

 NO

Do you have any sinus or allergy problems?

If YES, please list: ______________________________________________________________________________

 YES

 NO

Are you a diabetic?

 YES

 NO

If YES, are you insulin-dependent?

 YES

 NO

Have you ever been exposed to excessive loud noise?

 YES

 NO

Do you have a history of firearm use?

 YES

 NO

Do you have ringing or other noises in your ears?

If YES, which ear? _________________________

 YES

 NO

Have you ever had your hearing tested?

If YES, by whom and when? ______________________________________________________________________

 YES

 NO

Have you ever received any medical or surgical treatment for your ears or hearing loss?

If YES, explain and include dates if possible _________________________________________________________

_____________________________________________________________________________________________

Please list any medications you are currently taking here or provide a copy of a list ________________________

_____________________________________________________________________________________________

Amplification History

 YES

 NO

Do you currently wear any amplification device?

Ear fitted:  BOTH  LEFT  RIGHT

If YES, what type? ___________________

If YES, and you could improve something about your current device, what would that be?

_____________________________________________________________________________________________

 YES

 NO

Do you know anyone who wears hearings aids?

If YES, who? _____________________________

Is there anything else you would like Dr. Spector to know about yourself or medical history that was not

included on this form? _________________________________________________________________________

_____________________________________________________________________________________________

Patient Intake Form Page 2

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