Patient Forms from Advanced Hearing Solutions, Inc. in West Virginia Step 1 of 4 25% Client HistoryToday's Date* MM slash DD slash YYYY Name* First Middle Initial Last Gender Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhoneDate of Birth* MM slash DD slash YYYY Status Married Single Widow(er) Email Address* OccupationIf retired, what kind of work did you do?Who will be with you at your appointment?Relationship?Family Physician NameFamily Physician CityFamily Physician PhoneInsurance CarrierI.D. No./Policy No.Permission to release test information to physician? Yes No Permission to release test information to designated person(s)? Yes No Name & RelationshipPatient's Signature*How did you hear about us?If you were referred to us, who may we thank? Medical HistoryDo you have any allergies? Yes No Please listAre you an insulin-dependent diabetic? Yes No Are you currently taking any medications? Yes No Please listDo you have any arthritis? Yes No Are you taking any blood thinners? Yes No Please listHave you been examined by a doctor in the last 6 months? Yes No Have you received any medical or surgical treatment for your hearing loss? Yes No Hearing Health HistoryWhen was your last hearing test? MM slash DD slash YYYY What was the result or recommendation from that exam?In what ear is your hearing most impaied? Left Right Same When did you first notice a decline in your hearing? Within the past... 90 days 1-3 years 4-6 years 7-10 years 10+ years Do you know the cause of your hearing loss? (Have you been around excessive noise?) Yes No Please explainHave you noticed any change in your ability to remember? Yes No Do you have ringing in your ears? Yes No Do you sometimes hear converstaion loud enough but cannot understand the words? Yes No Do you often ask others to repeat? Yes No Do you find it difficult to understand conversation in noise? Yes No Do you have trouble hearing on the telephone? Yes No Do you have trouble hearing your spouse? Others? Women? Children? Yes No Do others mention you play the radio or TV too loudly? Yes No What comments have others made about your hearing?What brings you in to our clinic today?In what situation do you have the most difficulty understanding, or in what situation would you like to hear better?If hearing loss is discovered, and we find that hearing aids will help you, are you ready for help today? Yes No Amplification HistoryAre you a current hearing aid wearer? Yes No TypeEar fitted Both Left Right If you could improve something about your current hearing aids, what would it be?Do you know anyone who wears hearing aids? Yes No Who? Δ
