Surveypoint

Q1

Name*

Prefix

Q2

Name*

First Name

Q3

Name*

Last Name

Q4

I am*

Male

Female

Q5

Address*

Street Address

Q6

Address*

Street Address Line 2

Q7

Address*

City

Q8

Address*

State / Province

Q9

Address*

Postal / Zip Code

Q10

Home Phone

Phone Number

Q11

Work Phone

Phone Number

Q12

Cell Phone

Phone Number

Q13

Email

Q14

Date of Birth*

Q15

Referred by

Q16

Reason for first visit

Q17

Provide Specific Details

Q18

Family Dr. Name

Q19

Family Dr. Phone

Phone Number

Q20

Family Dr. Fax

Phone Number

Q21

Name

Q22

Phone Number

Q23

Have You Had Your Hearing Tested Before?*

Yes

No

Q24

Have You Worn a Hearing Aid Before?*

Yes

No

Q25

Have Family or Friends Commented on Your Hearing?*

Yes

No

Q26

Type a question

Diabetes

High Blood Pressure

Heart Problems

Kidney Problems

Pain in Your Ears

Chemotherapy

Ringing or Buzzing

IV Antibiotics

Migraines

Family History of Hearing Loss

History of Ear Infections

History of Noise Exposure

History of Ear Surgery

Dizziness

Ear Surgery

Hearing or Ear Trauma

Hearing Fluctuation

Radiation Therapy

Q27

Type of Noise Exposure

Farm Equipment

Hunting/Shooting

Music

Factory Noise

Work

Power Tools

Jet Engines

Hobbies

Military

Q28

Do You Take a Blood Thinner? (Coumadin, Plavix etc.)

Yes

No

Q29

I consent for you to release my hearing healthcare records (or my child's) to the following people:

Q30

Audiology Patient Intake Form -Form Fill

Name*

Name*

Name*

I am*

Address*

Address*

Address*

Address*

Address*

Home Phone

Work Phone

Cell Phone

Email

Date of Birth*

Referred by

Reason for first visit

Provide Specific Details

Family Dr. Name

Family Dr. Phone

Family Dr. Fax

Name

Phone Number

Have You Had Your Hearing Tested Before?*

Have You Worn a Hearing Aid Before?*

Have Family or Friends Commented on Your Hearing?*

Type a question

Type of Noise Exposure

Do You Take a Blood Thinner? (Coumadin, Plavix etc.)

I consent for you to release my hearing healthcare records (or my child's) to the following people:

Date