The Place for Better Hearing 3302 Westbourne Drive Cincinnati, OH45248 (513) 922-0123
PATIENT INFORMATION
Patients Legal Name ______Date of Birth ______
Address ______City ______State____ Zip______
Home Phone ______Work Phone______Cell Phone ______
Email Address______Employer______
Please tell us how you heard about The Place for Better Hearing
______
Family Doctor ______Referring Doctor______
If we perform a hearing test, would you like a copy sent to your family Doctor: YES NO
Emergency Contact (outside of your household) Name:______
Phone #: ______
Marital Status (circle one): SINGLEMARRIEDOTHER
Spouse or significant others name: ______
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE OF
THE PLACE FOR BETTER HEARING, INC.
I acknowledge that I have reviewed and/or received a copy of The Place for Better
Hearing’s notice of Privacy Practice and have accepted it as stated.
X______
Signature of Patient or Power of Attorney
MY SIGNATURE IS:
1. Authorization for treatment.
2. Authorization to pay benefits to The Place for Better Hearing, Inc.; I hereby authorize payment
directly to The Place for Better Hearing benefits, if any, for audiometric testing and/or hearing aid
purchased and fitting. I understand that my signature is agreement to pay for services not covered,
deductible amounts, and co-insurance due.Insurance benefits quoted are not a guarantee of payment.
3. I acknowledge that The Place for Better Hearing will apply a $5 service fee monthly for all accounts
90 days past due.
4. Authorization for The Place for Better Hearing to send communication regarding follow-up
Appointments and warranty information as well as product information and promotions.
X______Date: ______
Signature of Patient or Power of Attorney
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PLEASE ANSWER THE FOLLOWING QUESTIONS:
1. Do you feel you have hearing loss? YES NO
2. If yes, did this happen suddenly? YES NO
3. Do you have any family history of hearing loss? YES NO
4. Do you presently wear hearing aids? YES NO
5. Do you have pain or fullness in your ears? YES NO
6. Do you have drainage from your ears? YES NO
7. Do you consider dizziness to be a problem for you? YES NO
8. Do you experience ringing or buzzing sounds in one or YES NO
both ears?
9. Have you seen a medical doctor in the past six months? YES NO
10. Are you currently taking blood thinners? YES NO
11. Do you receive Medicare benefits? YES NO
12. If you are interested in purchasing hearing aids today,
would you like us to check your Insurance benefits? YES NO
Please list all medications including over the counter that you are currently taking:
______
______
______
Patients Legal Name______
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Lifestyle Solutions
Please answer the following questions by circling the answer that best applies:
How often do you participate in each activity?
Reading a book or magazine Rarely/Never OccasionallyOften Very Often
One on One Conversation Rarely/Never OccasionallyOften Very Often
Watching Television Rarely/NeverOccasionally Often Very Often
Outdoor Activities Rarely/NeverOccasionallyOften Very Often
Places of Worship/ Theater Rarely/NeverOccasionallyOften Very Often
Workplace Meetings Rarely/NeverOccasionallyOften Very Often
Listening to Music Rarely/NeverOccasionallyOften Very Often
At a Restaurant Rarely/NeverOccasionallyOften Very Often
Work or Recreational Noise Rarely/NeverOccasionallyOften Very Often
Parties/ Social Gatherings Rarely/NeverOccasionallyOften Very Often
Name:______Date:______
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