Patient Forms from Advanced Hearing Solutions, Inc. in West Virginia Step 1 of 4 25% Client HistoryToday's Date* Name* First Middle Initial Last GenderMaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhoneDate of Birth* StatusMarriedSingleWidow(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?YesNoPermission to release test information to designated person(s)?YesNoName & 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?YesNoPlease listAre you an insulin-dependent diabetic?YesNoAre you currently taking any medications?YesNoPlease listDo you have any arthritis?YesNoAre you taking any blood thinners?YesNoPlease listHave you been examined by a doctor in the last 6 months?YesNoHave you received any medical or surgical treatment for your hearing loss?YesNo Hearing Health HistoryWhen was your last hearing test? What was the result or recommendation from that exam?In what ear is your hearing most impaied?LeftRightSameWhen did you first notice a decline in your hearing? Within the past...90 days1-3 years4-6 years7-10 years10+ yearsDo you know the cause of your hearing loss? (Have you been around excessive noise?)YesNoPlease explainHave you noticed any change in your ability to remember?YesNoDo you have ringing in your ears?YesNoDo you sometimes hear converstaion loud enough but cannot understand the words?YesNoDo you often ask others to repeat?YesNoDo you find it difficult to understand conversation in noise?YesNoDo you have trouble hearing on the telephone?YesNoDo you have trouble hearing your spouse? Others? Women? Children?YesNoDo others mention you play the radio or TV too loudly?YesNoWhat 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?YesNo Amplification HistoryAre you a current hearing aid wearer?YesNoTypeEar fittedBothLeftRightIf you could improve something about your current hearing aids, what would it be?Do you know anyone who wears hearing aids?YesNoWho?
