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Audiology Patient Intake Form

Collects a new patient's personal details, hearing history, and health background before their first visit to an audiology clinic.

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Patient Information

Full Name*

Nombre

Apellido

I am*

Patient Parent or guardian, completing for a minor

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Home Phone

Work Phone

Cell Phone

Date of Birth*

Referred By

Reason for First Visit

Provide Specific Details

Family Physician

Family Doctor's Name

Family Doctor's Phone

Family Doctor's Fax

Emergency Contact

Name

Phone Number

Hearing History

Have You Had Your Hearing Tested Before?*

Yes No

Have You Worn a Hearing Aid Before?*

Yes No

Have Family or Friends Commented on Your Hearing?*

Yes No

Symptoms You Are Experiencing

Ringing in the ears (tinnitus) Ear pain Dizziness or balance problems Hearing loss Ear discharge Feeling of ear fullness

Type of Noise Exposure

Workplace machinery Loud music or concerts Firearms Military service Power tools None of the above

Do You Take a Blood Thinner? (Coumadin, Plavix, etc.)

Yes No

Consent

I consent for you to release my hearing healthcare records (or my child's) to the following people:

Signature*

Sign here

Date

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