Audiology Patient Intake Questionnaire
Audiology Patient Intake Questionnaire
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Reason for Visit
*
Routine Hearing Evaluation
Hearing Difficulty
Tinnitus (Ringing in Ears)
Dizziness/Balance Issues
Other
Do you currently use a hearing aid or other hearing device?
*
Yes
No
Please describe any current hearing concerns or symptoms.
Relevant Medical History (Check all that apply)
Ear Infections
Ear Surgery
Noise Exposure
Family History of Hearing Loss
None of the above
Other
Primary Care Physician Name
Emergency Contact Name & Phone
Submit
Should be Empty: