Medical History

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Patient Name: _________________________________________ Medical History Have you ever had a hearing test? {YES} {NO} If so, when? ____________________ Have you noticed that … (please check all that apply): _____People seem to mumble? _____That you hear words but cannot understand them? _____You find it difficult to hear in noisy places? _____You ask people to repeat themselves? _____Others complain that your television is too loud?

Please check all medical conditions that apply: _____ Dizziness or Unsteadiness _____ Ear Deformity _____ Ear Drainage _____ History of ear infections _____ Diabetes _____ AIDS/HIV _____ Arthritis _____ History of Cancer _____ Measles _____ History of High Fever _____ Meningitis _____ Scarlet Fever _____ High Blood Pressure _____ Stroke/Heart attack (When? __________) _____ Radiation therapy/Chemotherapy _____ Cognitive ability _____ TMJ _____ Ear pain (Which ear? __________) _____ Premature birth, if child _____ Head injury _____ Family history of hearing loss _____ History of ear wax buildup _____ Mumps _____ History of hearing aid use (If so, what kind? _________________________) _____ Noise exposure (If so, what kind & when? _________________________) _____ Sudden hearing loss (If so, which ear? ____________________) _____ Previous Ear Surgery (If so, when, what type & which ear? ______________________________) _____ Developmental Disorders/Delays (If so, please explain. _________________________________) _____ Tinnitus/Ringing in the ears (If so, {one} or {both ears}? {Constant} or {intermittent}?) _____ Other (Please explain. ________________________________________________) Do you have any allergies to any medications, plastics, latex, etc? {YES} {NO} Current medications (blood thinners, antibiotics, etc) __________________________________ Do you have regular MRIs? {YES} {NO} Please list all major surgeries and illnesses in the past TEN years ________________________ _____________________________________________________________________________

Authorization for use and/or disclosure of Health Information/Release of Information: _____ I acknowledge that I have received and reviewed the Health Insurance Portability & Accountability Act (HIPPAA) policy of this office. _____ I give permission to Hearing Services to release information, verbal and written (contained in my medical record and other related information), to my insurance company, rehab nurse, case manager, attorney, employer (when an industrial test has been done), related healthcare providers, assignees and/or beneficiaries and all other related persons. I understand if the person or entity that receives this information is not a health care provider, the released information may be re-disclosed by the recipient and my no longer be protected by federal or state law. Information without patient identifiers may be used for quality purposes. I understand that that this authorization expires five years from the date of authorization listed below and may be revoked, at any time, by notifying Hearing Services and Hearing Aid Center, Inc. in writing.

Signature of Patient or Guardian (if under 18): __________________________________________ Printed Name: ___________________________________ Date: __________________________