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Patient Name:____________________DOB___________
Referring Physician:______________________________
Reason for visit:_________________________________
Patient Intake Questionnaire
General Hearing History:
1) When and where was your last hearing test?
2) Were hearing aids or any corrective procedures recommended?
3) Do you wear hearing aids? If so, what brand?
4) What were the results of wearing your hearing aids?
5) What results and features would you like in hearing aids?
6) Do you have a family history of hearing loss? If yes, who?
7) Do you have a family history of dementia? If yes, who?
8) Which situations do you find it difficult to hear in?
9) Do you experience ringing in your ears (tinnitus)?
10) Are you diabetic?
11) Have you had prolonged (>1 year) exposure to blood thiners?
Social History:
Employment Status: Disabled Full Time Light Duty Retired Student Unemployed
Do you experience any of the following in social situations?
Difficulty hearing women or children's voices
Ask people to repeat themselves
Difficulty hearing in noisy environments
Others complain the TV or radio is too loud
Difficulty hearing on the phone
You hear, but can't make out what others are saying at times
Feel tired or stressed when listening for long periods of time
Would rather be alone than have to interact with others
Medical Clearance Questions:
1) Do you have any deformity to your ears?
2) Do you have any pain in your ear?
3) Do you experience persistent or regular dizziness?
4) Any drainage from your ears?
5) Have you had wax removed from your ears?
6) Have you had a sudden loss of hearing in the past 90-days?
7) Have you experienced drainage from your ears?
8) Do you hear better in one ear than the other?