Patient Intake Form

ADVERTISEMENT

PATIENT INTAKE FORM
CLIENT HISTORY
PLEASE PRINT
Today’s Date ______ - ______ - ______
Last Name ________________________________________
First Name ____________________________________
MI _________
Address ________________________________________________________
o Male o Female o Married o Single o Widow(er)
City __________________________________
State ___________________
Zip _____________
County ___________________
Phone (
) _______ - ___________
E-mail address ________________________________________________________________
Date of Birth ______ - ______ - ______
Past/Present Occupation _______________________________________________________
Accompanying Party or Companion ________________________________
Relationship ____________________________________
Family Physician Name ________________________________
City ________________________
Phone _____________________
Insurance Carrier ____________________________________________
I.D. No./Policy No. ___________________________________
Permission to release a copy of test information to physician? o Yes o No
Patient’s Signature _______________________________
MEDICAL AND HEARING HEALTH HISTORY
Do you have any of the following:
Deformity of the ear?
o Yes o No
Sudden or rapid hearing loss in the past 90 days?
o Yes o No
Pain or discomfort in the ear?
o Yes o No
Acute or recurring dizziness?
o Yes o No
Previous ear infections?
o Yes o No
Active drainage from the ear?
o Yes o No
Have you ever found it necessary to have a doctor remove wax from your ears?
o Yes o No
In which ear have you noticed difficulty hearing?
o Both o Left o Right
Do you have any sinus or allergy problems?
o Yes o No
If yes, please list _________________________________________
Are you a diabetic?
o Yes o No
If yes, are you insulin-dependant? __________________________
Have you had exposure to excessive noise?
o Yes o No
Do you have a history of firearm use?
o Yes o No
Which ear do you use on the telephone?
o Right o Left
Do you have ringing or other noises in your ears? o Yes o No
If yes, which ear? ________________________________________
Have you previously had a hearing test?
o Yes o No
If yes, by whom and when? _______________________________
Have you received any medical or surgical treatment for your hearing loss? o Yes o No
If yes, when? __________________________
Explain _________________________________________________________________
Physician/ENT _______________________________________
City ________________________
Phone _____________________
AMPLIFICATION HISTORY
Are you a current hearing aid wearer? o Yes o No Type _______________________________
Ear fitted: o Both o Left o Right
If yes, and you could improve something about your current hearing aids, what would that be? ________________________________
_______________________________________________________________________________________________________________
Do you know anyone who wears hearing aids? o Yes o No
If yes, who? _________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Business
Patient Intake Form Patient Intake Form Medical

Related Categories

Parent category: Business
Download
Go