Hearing Center Patient Intake Form

Patient intake and history form for retail hearing centers to document presenting concerns, prior hearing aid use, occupational noise exposure, and physician referral details.

Consent, Privacy, and Submission Notice

• I consent to the collection and use of my information for hearing center intake and service planning.
• I understand this form may include PII and health-related information, and I agree to provide only information relevant to my hearing care.
• I understand my submission will be reviewed by hearing center staff and recorded in the audit trail.

Patient Identification and Contact Details

• Full Name
• Date of Birth
  Optional. Only collect if needed to distinguish records or confirm eligibility.
• Phone Number
• Email Address
• Preferred Contact Method

Presenting Hearing Concern

• What is your main hearing concern?
• How long have you noticed this concern?
• In which situations is hearing most difficult?
• If other, please describe

Prior Hearing Aid and Hearing Care History

• Have you used hearing aids or other hearing devices before?
• Tell us about your prior hearing aid or hearing device use
  Include device type, approximate year used, and whether it was helpful.
• Are you currently wearing hearing aids or another hearing device?
• Brand and model, if known

Noise Exposure History

• Have you had regular occupational noise exposure?
• Describe the work environment and noise exposure
  Examples: manufacturing, construction, aviation, music, machinery, or other loud environments.
• Do you have regular recreational noise exposure?
• Do you use hearing protection in noisy settings?

Physician Referral and Medical Coordination

• Were you referred by a physician or other healthcare professional?
• Referring Provider Name
• Referring Clinic or Practice
• Reason for Referral

Additional Notes and Accessibility Needs

• Communication Preferences
• Do you need any reasonable accommodation for your visit?
  Include only what is needed to support access to the appointment.
• Additional Notes