patient information and history form

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PATIENT INFORMATION AND HISTORY FORM Name: _______________________________________________________

Date: ______________________

Address: _____________________________________________________

DOB:____________ Age:______

City: ________________________________ State: _______ Zip:________

SS # ______________________

Home Phone: _________________ Cell Phone: __________________ Email: ___________________________ Marital Status: Single/Married/Widowed/Minor/Divorced Name of Spouse: ___________________________ Gender: Male Female

Occupation: _______________________________________

How did you hear about us? Physician Ref. Internet Newspaper Direct Mail Patient Referral Community Event Previous Patient

__________________________________________________________________________________________ Referring/Primary Care Physician: _________________________________ Phone: _____________________ Permission to release copy of test information to physician?

Yes

No

Primary Insurance: ______________________________________ ID/Policy Number:____________________ Group Number: ___________ Insured Name:____________________________ Date of Birth: ____________ Secondary Insurance: ___________________________________ ID/Policy Number: ____________________ Group Number: ___________ Insured Name:____________________________ Date of Birth: ____________ Please read and sign below: I authorize the release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to Professional Hearing Associates. I understand and agree to be personally responsible for the balance and/or deductibles as stipulated by my policy. Also, my signature confirms that I have been made available a copy of Professional Hearing Associate’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose confidential information. I understand that this practice has reserved the right to change privacy practices that are described in the Notice. In addition, I understand that in the event the policy is revised, a copy of the revised notice will be provided to me or made available at the next office visit.

I, hereby give my consent to Professional Hearing Associates to use and/or disclose certain protected health information for the purpose of carrying out treatment, payment, or health care operations regarding all the information contained in the patient record of ________________________________________. (Patient Name)

I understand that I do not have to sign this authorization in order to receive treatment and have the right to refuse to sign this authorization. I have the right to revoke this authorization

Signed: _____________________________________________ Date:________________________________ I, _________________________________, hereby authorize release my health information for verbal discussion only of my care and treatment to the person(s) listed below: Name: _________________________ Relationship to Patient:_____________________ Phone: ___________

MEDICAL/HEARING HISTORY Is there a family history of hearing loss? Yes No If Yes, who? ________________________ Is there diabetes in your family? Yes No Earaches or drainage within the past 90 days? Yes No Have you had your hearing tested? Yes No By whom: __________________________ Medical/Surgical treatment for your ears? Yes No By whom: __________________________ Do you have pain in your ears? Yes No Sudden or rapid hearing loss in the past 90 days? Yes No Hearing loss in one ear in the last 90 days? Yes No Any dizziness (spinning, unsteady, lightheaded)? Yes No Are you taking blood thinners? Yes No Do you wear a pace maker? Yes No Have you seen a Dr. for wax removal? Yes No Which is the poorer ear? Right Left Same Do you notice any tinnitus (ringing/buzzing/roaring)? Yes No If Yes, which ear? Right Left Both Can’t Tell Is it bothersome? Yes No How frequently? All the time Occasionally History of loud noise-recreational or occupational? Yes No

Have you ever had any of the following? Arthritis

Depression

High fever/mumps

Multiple Sclerosis

Allergies

Dementia/Alzheimer’s

HIV/AIDS

Pacemaker

Anxiety

Headaches/Migraines

Hyperthyroidism

Parkinson’s

Bell’s Palsy

Head Trauma

Hypothyroidism

Seizures

Cancer

Hepatitus

Kidney/Renal

Stroke

Diabetes

High Blood Pressure

Meningitis

Vascular Problems

Other:_______________________ Current Medications Name, Dose, Frequency): _________________________________________________ ________________________________________________________________________________________ Who did you bring with you today? ___________________________________________________________