This form is HIPAA compliance. Data collected is kept secure.
Your name:
Birth date:
/
Month
/
Day
Year
Date
OHIP:
Optional
Primary physician:
Address:
Postal Code:
Phone Number:
-
Area Code
Phone Number
Email address:
example@example.com
Emergency contact name and phone:
Relationship to patient:
1. What is your primary complaint with your ears and/or hearing?
Where do you want to hear better?
Family, Friends, and Social Settings
At home and during everyday
Hearing in the workplace
Have you sought help for your hearing within past 12 months?
Yes
No
If yes, Explain:
Do loved ones or friends comment about your hearing?
Yes
No
If yes, Explain:
Hearing aid(s) experience:
I use hearing aid(s) regularly
have hearing aid(s) but rarely use them
I have never used hearing aid(s)
I had my hearing tested at another office but never tried wearing it
I once tried hearing aid(s) but with no success
Do you have:
Ear Pain
Ear Drainage
Fullness in Ear
Ringing in Ear
Please check all that apply:
Pacemaker
Visual problems
Aspirin therapy
Diabetes
High blood pressure
Release of Information: Do we have your permission to release information about your hearing to your family doctor, Ministry of Health, ADP (Assistive Devices Program), Insurance or a third party payeee (DVA WSIP, ODSP, etc.)?
Yes
No
Signature:
Clear
Submit
Should be Empty: