To download a PDF of this form, please CLICK HERE!

Personal Information:




MF






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.