The Visiting Audiologists
Administrative Office
445 Hamilton Ave., Suite 1102
White Plains, NY 10601

Printable Form
Download the Printable Form

Patient Form

PERSONAL INFORMATION

May we contact you via email?

MEDICAL INFORMATION

Do you have pain/discomfort in your ear?*

If Yes, which ear?

Do you have you any drainage in your ear?*

If Yes, which ear?

Do you have a history of ear infections?*

Do have ringing or other noises in your ear?*

If Yes, which ear?

Is it constant or intermittent?

Do you have dizziness or vertigo?*

Have you ever had ear surgery?*

If Yes, which ear?

Please describe other medical conditions we should be aware of?

HEARING

Do you think you have a hearing loss?*

Is there a family history of hearing loss?*

Have you had noise exposure?*

Have you had your hearing tested before?*

If Yes, When?

Do you currently use a hearing aid?*

If Yes, for how long?

AREAS OF DIFFICULTY

Rate the areas you have difficulty hearing or understanding as follows: Never - Rarely - Sometimes - Often - Always

When speaking with one person (i.e., spouse, store clerk)*

When speaking with small group (i.e., small dinner party)*

When in a noisy environment (i.e., riding in a car, restaurants, parties)*

When using communication devices (i.e., telephone, doorbell, PA systems)*

Do you feel your hearing limits your personal or social life?*

If Yes, please rate

Do problems or difficulty with your hearing upset you?*

Do other people suggest you have a hearing problem?*

Please tell us anything else you want to share about your hearing

NOTICE OF PRIVATE PRACTICE ACKNOWLEDGMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information.

Conduct, plan and direct my treatment and follow-ups among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations.

Signature*

Date

Patient Form

Patient Form

PERSONAL INFORMATION

MEDICAL INFORMATION

HEARING

AREAS OF DIFFICULTY

NOTICE OF PRIVATE PRACTICE ACKNOWLEDGMENT

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