To download a PDF of this form, please CLICK HERE! Personal Information: Name * Date of Birth * Gender * MF Phone # * Email Employer * Occupation * Primary Care Physician * What is the reason for your visit (primary concern)? * Hearing History: Do you feel you have hearing loss? * YesNo If YES, is one ear worse? * RightLeftBoth the Same Has your hearing loss occurred gradually or very suddenly? * GradualSudden When did you first notice your hearing loss? * Have you ever had your hearing tested? * YesNo If YES, when? * If YES, result? * Have you ever worked in a loud place or participated in loud activities? * YesNo If YES, explain? * Do you use hearing protection at work or during these loud activities? * YesNo Do you hear ringing or buzzing in your ears (tinnitus)? * YesNo If YES, which ear(s)? * RightLeftBoth If YES, does it bother you? * YesNo Is the tinnitus constant or occasional? * ConstantOccasional When did your tinnitus begin? * What does your tinnitus sound like? * Does anyone else in your family have difficulty hearing? * YesNo If YES, who? * Medical History: Do you have a history of ear infections or ear surgery? * YesNo If YES, Explain? * Have you ever seen a doctor for an ear-related issue? * YesNo If YES, name of doctor? * Date of visit * Pain in your ears? * YesNo If YES, which ear(s)? * RightLeftBoth Drainage from your ears? * YesNo If YES, which ear(s)? * RightLeftBoth Dizziness or imbalance? * YesNo If YES, it is: * ConstantOccasional When did it begin and please describe? * Do you have any chronic medical conditions? * YesNo If YES, list: * Do you have any allergies (ex. Latex, Acrylic, dyes)? * YesNo If YES, list: * Do you take any blood thinners? (ex. Coumadin, Plavix, Warfarin, aspirin) * YesNo Have you used a tobacco product (ex. cigarette, cigar, smokeless tobacco) one or more times in the past 24 months? * YesNo If yes, how often have you used a tobacco product in the past 24 months? * If yes, what type(s) of products have you used? * Do you currently take any medications or vitamins? * YesNo Please list all your medications, vitamins, etc (name, dosage, route (mouth, injection, etc.), reason) * Name Dosage Frequency Route Reason 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 What motivated you to set the appointment for your hearing test? * What is your hearing aid experience? (Check all that apply) * 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 list the top 3 situations you would most like to hear better. Be as specific as possible. * Please rank your most important consideration regarding hearing aids with 1 as most and 4 as least important. 1234 Hearing aid size and the ability of others not to see the hearing aids * 1234 Improved ability to hear and understand speech * 1234 Improved ability to understand speech in noisy situations (e.g. restaurants, parties, etc.) * 1234 Cost of the hearing aid system * On a scale of 1 to 10, with 1 being "not at all ready" and 10 being "very ready", how ready are you to get help for your hearing difficulty?* 12345678910 What office are you going to your for your appointment? * AmherstWilliamsvilleOrchard ParkTonawanda Signature * Date * Please arrive 15 minutes prior to your scheduled appointment time.