Confidential Patient Record

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Confidential Patient Record Date ____/____/____ Phone ( ) ______ - ________ Name __________________________________________________________________ □ Male □ Female Last

First

Initial

Address __________________________________________________________________________________ Street

□Married

City

□Single

□Widow(er)

State

Zip

Observing Party_____________________________ Name

Relationship

Date of Birth______/______/______ Email: ____________________________ Family Physician Name ______________________________________ Phone __________________________ Address ____________________________________________________________________________ Street

City

State

Zip

Type of Health Insurance_____________________________________________________________________ Have you ever had a professional hearing test? ___________________________________________________ If so, when and where was your most recent exam? _______________________________________________ Was there anything recommended as a result of this exam? _________________________________________ Amplification History

Current Hearing Aid wearer: □ Yes

□ No

Type____________________________________

If yes, and you could improve 2-3 things about your current hearing instrument, what would they be? ________ Do you have any allergies? □ Yes Do you have arthritis? □ Yes Please list medications:

Medical History □ No Are you an insulin-dependent diabetic? □ Yes □ No Are you currently taking any medications? □ Yes

□ No □ No

Have you ever received any medical or surgical treatment for a hearing loss: □ Yes □ No If yes, when? _______________ Physician/ENT:__________________________ Phone: _________________ Address ____________________________________________________________________________ Street

City

State

Zip

Additional Information about treatment: ______________________________________________________ _______________________________________________________________________________________ To Be Completed By Hearing Instrument Specialist *Visible congenital or traumatic deformity of the ear? *Visible evidence of significant cerumen accumulation or a foreign body in the ear canal? *Any history of, or active drainage from, the ear within the previous 90 days? *Any history of sudden or rapidly progressive hearing loss within the previous 90 days? * Have you experienced any acute or chronic dizziness? *Is there a unilateral hearing loss of sudden or recent onset within the previous 90 days? *Have you experienced any pain or discomfort? *Audiometric air-bone gap equal to, or greater than 15dB at 500Hz, 1000Hz, and 2000Hz?

□ Yes □ Yes □ Yes □ Yes □ Yes □ Yes □ Yes □ Yes

□ No □ No □ No □ No □ No □ No □ No □ No

Comments: ______________________________________________________________________________ ________________________________________________________________________________________ Representative _________________________________ Registration Number: _______________________ *If answer is “Yes” to any of these questions, patient must be referred to a physician or ear specialist prior to a hearing instrument fitting.

THE COUNSELING PROTOCOL 1) Mr/Mrs/Ms. (Patient), who encouraged you to come see a hearing professional today? 2) What sort of things has your (Companion) been saying to you about the level of communication between the two of you? 3) (Companion), what sort of things have you noticed about the level of communication between you and your (Patient)? 4) (Companion), how “Long” has effective communication been an issue with your (Companion)? (obtain a specific number) 5) (Patient) how “Long” have you been aware of this communication issue with your (Companion)? (obtain a specific number) 6) (Companion), do these difficulties in communication with your (Patient) CONCERN you? (get full and complete answer) 7) (Patient), does your (Companion’s) CONCERN about your communication as a couple CONCERN you? 8) Then, (Patient), given your CONCERN, would it be fair to say that you are not only here for your (Companion), but you are also here for YOURSELF? 9) (Companion), you said that you have been aware of this communication difficulty with your (Patient) for (#) years. Do I have that right? (Companion) (confirms) 10) (Patient) you said that you have been aware of these communication difficulties for only (#) years, do I have that right? (patient will confirm) 11) However, you did not come in (#) years ago, or (#) months ago, or even (#) weeks ago. What was it about NOW? 12) (Patient) what other environments do you find the level of communication less than you would like it to be? 13) (Patient) if I could help you communicate more effectively in environment 4, 3, 2 and especially 1, Is that the RESULT that you are looking for? 14) (Patient) how would this RESULT impact the daily quality of your life

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