Intake Form


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Confidential Patient Information 1. PATIENT INFORMATION Name: _____________________________________________________________ Date of Birth: ___________________ Age: _____________ Address: ________________________________________________ City: ______________________ State: ______ Zip: ______________ Home Phone: ___________________________ ________________________ Cell Phone __________________________________________ Emergency Phone _______________________________________________ Email address _______________________________________ Please circle all that apply

Male/Female

Employed/Retired/Other

Married/Single/Other

Companion/Relative Name: __________________________________________________ Phone: ___________________________________ Referring Physician: ____________________________________________________ Phone: ________________________________________

□Patient Referral □Physician Referral □Direct Mail □Website □Facebook □ Google Internet □ Other (please specify) _________________________________________________________________________

How did you hear about us?

□ Yellow Pages 2.

2. MEDICAL INFORMATION

□ YES Have you ever had your hearing tested? □ YES Is there a history of diabetes in the family? □ YES Are you taking blood thinners? □ YES Have you ever had ear surgery?

3.

□ NO □ NO □ NO □ NO

By Whom? _______________________________________________________ By Whom? _______________________________________________________ How many prescription drugs do you take daily? _________________________ Do you wear a pacemaker?

□YES □ NO ____________________________

ABOUT YOUR HEARING-Do you have any of these symptoms?

___ YES ___ NO Deformity of the ears? ___ YES ___ NO Hearing loss in one ear in the last 90 days? ___ YES ___ NO Do you have pain in your ears? ___ YES ___ NO Have you seen a doctor for wax removal? ___ YES ___ NO Sudden hearing loss in the last 90 days? ___ YES ___ NO Drainage from ears in the past 90 days? ___ YES ___ NO Sudden or long term dizziness? Which is your poorer ear? ___ Right ___ Left ___ Same Does anyone in your family have a hearing problem? ___ YES ___ NO Relationship to you? In what situation does your hearing problem give you the most trouble? __________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

4.

HEARING AID EXPERIENCE::

___ I have a hearing aid and use it regularly in my ___ RIGHT EAR ___ LEFT EAR ___ I have a hearing aid, but don’t use it, or use it occasionally. ___ I have tried a hearing aid, but returned it. ___ I have inquired about hearing aids from another office, but did not purchase. ___ I have never tried a hearing aid.

Please Complete Back Side →

Confidential Patient Information 5.

HEARING NEEDS ASSESSMENT::

Put a “1” before the FIRST thing that is most important to you in purchasing a hearing aid. Now put a “2” before the SECOND most important thing to you when purchasing a hearing aid. Next put a “3” before the THIRD most important thing to you when purchasing a hearing aid. Lastly, put a “4” before the LEAST important thing to you when purchasing a hearing aid. These are your choices: Appearance _____ Sound Quality & Clarity _____ Durability/Reliability _____ Cost _____ MOTIVATION SCALE: On a scale of 1-10, where do you feel that you are, regarding doing something about your hearing loss? (circle one) Not Motivated 6.

1

2

3

4

5

6

7

8

9

10

Very Motivated

TINNITUS: Do you have ringing (tinnitus) in your ears? No (move to Section 7 __Yes (answer 1-5 below)

□ LEFT EAR □ RIGHT EAR □ BOTH EARS 2. Which option best describes the head noise you are experiencing? □ HIGH PITCHED □ LOW PITCHED □ CRICKETS □ LOCUST □ OTHER: ___________________________________________________________________________________________________________ 1. Is your tinnitus in your

3. Describe the loudness of your tinnitus?____________________________________________________________________________________

□ VERY LOUD □ LOUD □ MODERATE □ FAINT □ VERY FAINT 4. Is your tinnitus: □ CONTINUOUS □ INTERMITTENT 5.When did the tinnitus start? _____________________________________________________________________________________________ ______________________________________________________________________________________________________________________

7. SELF QUESTIONNAIRE:: Please answer “YES”,”NO” or “SOMETIMES” to each of the following items. Do not skip a question if you avoid a situation because of a hearing problem. If you wear a hearing aid(s), answer the way you hear without the hearing aid(s): 1. Does your hearing problem cause you to feel frustrated when visiting with friends? ___ YES ___ NO ___ SOMETIMES 2. Does your hearing problem cause you to feel embarrassed when meeting new people? ___ YES ___ NO ___ SOMETIMES 3. Do you have difficulty hearing when someone is soft spoken or speaks at a distance? ___ YES ___ NO ___ SOMETIMES 4. Does your hearing problem cause you to attend social events less often than you’d like? ___ YES ___ NO ___ SOMETIMES 5. Does your hearing problem cause you to become fatigued by the end of the day? ___ YES ___ NO ___ SOMETIMES 6. Does your hearing problem cause you difficulty in a restaurant with relatives or friends? ___ YES ___ NO ___ SOMETIMES 7. Does your hearing problem cause you difficulty listening to TV or radio? ___ YES ___ NO ___ SOMETIMES 8. Does your hearing problem cause you to have arguments with family or friends? ___ YES ___ NO ___ SOMETIMES HIPPA RELEASE & AUTHORIZATION: ____ By placing an “X” on this line and signing below, you allow Her Again America to release all medical information to your insurance carrier(s). You also agree to accept financial responsibility for all charges which are non-covered and thus not paid to Hear Again America by your insurance carrier for services rendered by our office. This release is valid for life but may be revoked, in writing, at any time. Refusal to sign or revocation of this release will result in you being financially responsible for payment in full at any time of the visit. Signature of Patient or Guarantor: _______________________________ Date: _______________________