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    Personal Information:




    MF







    TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther




    Hearing History:


    YesNo


    GradualSudden


    YesNo



    YesNo


    YesNo

    YesNo


    YesNo

    ConstantOccasional



    YesNo

    Medical History:


    YesNo


    YesNo



    YesNo


    YesNo


    YesNo



    YesNo


    YesNo


    YesNo

    YesNo



    YesNo





    If you take more than six medications, please bring a detailed medication list to your appointment).

    Your Hearing Needs:

    If possible, please review this with someone who lives with you or communicates with you on a frequent basis



    I have a hearing aid and use it regularly in my right earI have a hearing aid and use it regularly in my left earI have a hearing aid and use it regularly in both earsI have inquired about hearing aids at another office but did not purchase at the timeI have a hearing aid, but don’t use it or only use it occasionally.I have never used a hearing aid.I have tried a hearing aid but returned it.None of the above

    Please rank your most important consideration regarding hearing aids with 1 as most and 4 as least important.


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    Please arrive 15 minutes prior to your scheduled appointment time.