Advanced Hearing Center

PATIENT INFORMATION

How did you hear about our office? Insurance Physician - Other

Patient Name: DOB://Age:__

Parent Name (if minor): ______E-mail: ______

Address: ______City: ______State: ______Zip: ______

Phone Numbers: Cell (_____)_____-______Work (_____)_____-______Ext.______Home (_____)______-______

Social Security #: ____-_-____Sex: M F Status: Single Married Widowed Divorced

PHYSICIAN INFORMATION

Family PhysicianOffice # ()-Fax # ()-__

AddressCity, State, Zip

PRIMARY INSURANCE INFORMATION

Ins. Company: ______Policyholder Name: ______

Relationship to Patient: Parent Guardian Spouse Self (please complete info. below)

Policyholder ID#: ______Group ID#:______Sex: M F DOB: ____/____/______

Policyholder Employer: ______

Does patient have Medicaid Secure Horizons Medicare Coverage? Yes No

SECONDARY INSURANCE INFORMATION

Ins. Company: ______Policyholder Name: ______

Relationship to Patient: Parent Guardian Spouse Self (please complete info. below)

Policyholder ID#: ______Group ID#:______Sex: M F DOB: ____/____/______

Policyholder Employer: ______

Release of Medical Records/Assignment of Insurance Benefits

1) In order to ensure proper follow-up and continuity of care, I agree that a copy of my medical record may be released to my physician, a designated referral physician, and/or the provider, if any, who referred me here. Yes No

2) I consent for Advanced Hearing Center to contact me regarding annual services, warranty renewals and any other special promotions. Yes No

3) I consent to be examined by the Audiologists/Practitioners at Advanced Hearing Center at each visit and request that payment of authorized benefits be made to Marilyn M. Hinrichs, Au.D. DBA Advanced Hearing Center on my behalf, for any services provided to me or my dependent. I authorize any holder of medical and other information about me to release to Medicare and its agents, any insurance carrier, any other third party payer, state medical assistance agency, or any other governmental or private payer responsible for paying such benefits, any information needed to determine these benefits or benefits for related services. I understand that I am financially responsible for any charges incurred regardless of any problems, which may arise with my insurance carrier. All charges, whether or not paid by my insurance carrier and a forty percent (40%) charge for all debt collection, will apply if needed. I authorize the use of this signature on all insurance claims submissions and a copy of this authorization to be used in place of its original. Yes No

Signature: ______Date: _____/_____/______

MEDICAL HISTORY

1) Primary reason for your visit today? ______

2) Has a doctor examined you in the past 6 months? Yes No

3) Are you currently taking any medications? Yes No – (If yes, list on separate medications sheet.)

4) Do you have: Diabetes Epilepsy Heart problems HIV/AIDS Hepatitis

5) Have you received chemotherapy treatment(s) or any other long-term drug treatment(s)? Yes No

6) If so, what and when? ______

7) Do you smoke? Yes No - If so, how many packs per day? ______

8) Do you consume alcoholic beverages? Yes No - If so, how frequent? ______

9) Do you use recreational drugs? Yes No - If so, what? ______

10) Will this be your first hearing test? Yes No

11) Have you ever had surgery? Yes No (If yes, what)______

12) Do you have any of the following:

i) ♦Deformity of the ear? Yes No

ii) ♦Sudden or rapid hearing loss in the past 90 days? Yes No

iii) ♦Acute or recurring dizziness? Yes No

13) Has your hearing in one ear worsened in the past 90 days? Yes No

14) Do you ever have ear pain? Yes No

15) Have you ever had wax removed from your ears by a doctor? Yes No

16) In which ear is your hearing the worst? Left Right Same

17) Have you put any medications or other substances (baby oil, alcohol, hot wax) in your ears? Yes No

18) If so, what and when? ______

PEDIATRIC MEDICAL HISTORY (TO BE COMPLETED BY PARENTS OR GUARDIAN)

1) What concerns are you having? ______

2) Was the pregnancy and birth history normal? Yes No

3) Did your child pass the newborn hearing screening? Yes No

4) Did your child have normal development milestones (speech, crawling, walking, etc.)? Yes No

5) Has the child had any major illnesses or hospitalizations? Yes No

6) If yes, what and when? ______

7) Has your child had any history of ear infections? Yes No

8) If yes, how frequent and most recent occurrence? ______

9) Has your child ever had tubes placed in their ear(s)? Yes No

10) If yes, which ear(s) and when? ______

11) What grade is your child in? ______

12) Are there any concerns with their classroom performance (grades, behavior, etc.)? Yes No

HEARING HISTORY

1) Do people seem to mumble? Yes No

2) Do you find yourself asking people to repeat what they have said? Yes No

3) Do you sometimes hear words but do not always understand them? Yes No

4) Do you find it difficult to hear in noisy places? Yes No

5) Have you been told that you speak loud? Yes No

6) Is it difficult to understand speech when your back is to the speaker? Yes No

7) Do others complain that you play the TV too loud? Yes No

8) Have you occasionally missed the ringing of a telephone? Yes No

9) Do you find it difficult to hear when using a telephone? Yes No

10) Do you avoid social events because of hearing difficulty? Yes No

11) How many years have you experienced hearing difficulty? ______

12) How did your hearing loss develop? Suddenly Gradually

13) Do you know the cause of your hearing loss? Yes No

14) Do you have a hearing instrument? Yes No

15) If a hearing loss is discovered, are you ready for help? Yes No

16) Do you have any history of noise exposure (loud music, gunfire, loud machinery/engines)? Yes No

17) Have you ever worn a hearing aid? Yes No (if yes, answer next section.)

18) Does anyone in your family have hearing loss? Yes No - If so, who? ______

HEARING INSTRUMENT USER (While wearing hearing instruments)

1) Do you hear but have difficulty understanding? Yes No

2) Do you have difficulty understanding when two or more are talking? Yes No

3) Do you have difficulty understanding when in a crowd? Yes No

4) Do you have difficulty understanding at a distance? Yes No

5) Do you have difficulty knowing from which direction sounds are coming? Yes No

6) Do you have difficulty while using a telephone? Yes No

7) Does your own voice sound hollow and unnatural? Yes No

8) Do words often run together? Yes No

9) Do your hearing instrument(s) make sounds loud enough? Yes No

10) Are some sounds too loud? Yes No

11) Do your hearing instrument(s) make sounds tinny? Yes No

12) Do your hearing instrument(s) whistle? Yes No

13) Do your hearing instrument(s) make your ears sore? Yes No

HEARING DIFFICULTY QUESTIONNAIRE

Listening Situations Hearing Quality Importance to You

(Poor) (Normal) (Not) (Somewhat) (Very)

Conversation in Quiet 1 2 3 4 5 1 2 3 4 5

Television 1 2 3 4 5 1 2 3 4 5

Leisure Activities 1 2 3 4 5 1 2 3 4 5

Restaurants 1 2 3 4 5 1 2 3 4 5

Meetings/Groups 1 2 3 4 5 1 2 3 4 5

Work Place 1 2 3 4 5 1 2 3 4 5

Telephone 1 2 3 4 5 1 2 3 4 5

Church 1 2 3 4 5 1 2 3 4 5

Male Voices 1 2 3 4 5 1 2 3 4 5

Female Voices 1 2 3 4 5 1 2 3 4 5

TINNITUS HISTORY

1) Do you have any symptoms of tinnitus (ringing, buzzing, hissing)? Yes No (If no, skip to next section.)

2) Which sound(s) do you hear? Ringing Buzzing Hissing Crickets Other: ______

3) Is it any of the following? (Check all that apply) Roaring Rushing Wooshing

4) Which ear? Right Left Both

5) When did it begin? ______

6) How frequent? (Check all that apply) Constant Intermittent Daily Hourly Other: ______

7) If pulsate or intermittent, how long does it last? ______

8) Is it occurring today? Yes No

9) Does it pulse with your heartbeat? Yes No

10) Please rate your tinnitus for annoyance on a scale of (0-10), with zero being not bothersome and ten being extremely bothersome and unable to function normally:

0 1 2 3 4 5 6 7 8 9 10

DIZZINESS/VERTIGO HISTORY

1) Do you have dizziness or vertigo symptoms? Yes No (If no, skip to next section.)

2) When did it begin? ______

3) How often does it occur? ______

4) How long do the episodes last? ______

5) Have you seen a physician regarding these symptoms? Yes No

6) If yes, when were you seen? ______

7) If yes, who is the physician? ______

8) What was the treatment? ______

CURRENT MEDICATIONS LIST (Please list all medications here.)

Medication Dosage (mg) Quantity per day Form (pill, injection, liquid)

1) ______

2) ______

3) ______

4) ______

5) ______

6) ______

7) ______

8) ______

9) ______

10) ______

11) ______

12) ______

13) ______

14) ______

15) ______

ANY ADDITIONAL INFORMATION:

______