Patient Form

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

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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

Schedule your appointment with us today.

To set up your in-home visit, simply fill out our online form, or call us at (914) 420-0064.