Patient Intake Form

Patient Intake Form
Your Personal Details
Name*
PrefixFirst NameLast Name
I am*
MaleFemale
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Home Phone
Area CodePhone Number
Work Phone
Area CodePhone Number
Cell Phone
Area CodePhone Number
Email
example@example.com
Date of Birth*
MonthDayYear
Date
Referred by
Reason for first visit
Provide Specific Details
Your Family Doctor
Family Dr. Name
Family Dr. Phone
Area CodePhone Number
Family Dr. Fax
Area CodePhone Number
Emergency Contact Details
Name
Phone Number
Area CodePhone Number
Your Health History
Have You Had Your Hearing Tested Before?*
YesNo
Have You Worn a Hearing Aid Before?*
YesNo
Have Family or Friends Commented on Your Hearing?*
YesNo
Type a question
DiabetesHigh Blood PressureHeart ProblemsKidney ProblemsPain in Your EarsChemotherapyRinging or BuzzingIV AntibioticsMigrainesFamily History of Hearing LossHistory of Ear InfectionsHistory of Noise ExposureHistory of Ear SurgeryDizzinessEar SurgeryHearing or Ear TraumaHearing FluctuationRadiation Therapy
Type of Noise Exposure
Farm EquipmentHunting/ShootingMusicFactory NoiseWorkPower ToolsJet EnginesHobbiesMilitaryOther
Do You Take a Blood Thinner? (Coumadin, Plavix etc.)
YesNo
A signature below acknowledges that you have received a copy of the HIPAA Privacy PRactices of this office.
I consent for you to release my hearing healthcare records (or my child's) to the following people:
Signature*
Clear
Date
MonthDayYear
Should be Empty: