Audiology Associates - New Patient History Form

Rows	Yes	No
Do you have a better hearing ear?
Have you experienced a sudden/progressive hearing loss in the last 90 days?
Have you had any ear surgeries?
Do you suffer from ear pain?
Do you have pressure or fullness in your ears?
Have you had chronic ear infections?
Do you have drainage from your ears?
Do you have a history of head trauma?
Do you have a family history of hearing loss?
Do you notice ringing/buzzing/tinnitus in your ears?
Do you have a history of excessive noise exposure?

Please rate your present hearing ability:

	1	2	3	4	5	6	7	8	9	10

1 is Perfect hearing, 10 is Severe hearing loss

What is the main reason you would like to improve your hearing and communication ability?

Please rate how motivated you are to use hearing aids:

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How much difficulty do you have hearing in the following situations?

Rows	No Difficulty	Slight Difficulty	Moderate Difficulty	Very much difficulty	Not Relevant
One on one conversations
Conversations in small groups
Conversations in large groups
Outdoors
Concerts/Theaters
Place of worship/lecture halls
Watching TV
In a car
Landline Phone
Cell Phone
Restaurants

Do you currently use a hearing aid?
List any problems you are having with your hearing aid(s):
Notice of Privacy Practices and Right to Bill
Please review and check the following boxes:

I hereby authorize all benefits for charges of examination and/or treatments requested to be paid to Audiology Associates of Redding. Verification of insurance coverage obtained over the phone does not guarantee payment. I have read this statement and accept full financial responsibility for all medical charges incurred by my dependents or me for services rendered by Audiology Associates of Redding.
(eg. spouse/caregivers/family members)
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

New Patient History Form