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Run: Hearing Center Patient Intake Form

A hearing center patient intake form for collecting hearing concerns, hearing aid history, noise exposure, referral details, and accessibility needs before t...

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Consent, Privacy, and Submission Notice

I consent to the collection and use of my information for hearing center intake and service planning. (required)

Yes No N/A

I understand this form may include PII and health-related information, and I agree to provide only information relevant to my hearing care. (required)

Yes No N/A

I understand my submission will be reviewed by hearing center staff and recorded in the audit trail. (required)

Yes No N/A

Patient Identification and Contact Details

Full Name (required)

Date of Birth

Optional. Only collect if needed to distinguish records or confirm eligibility.

Phone Number (required)

Email Address

Preferred Contact Method (required)

Presenting Hearing Concern

What is your main hearing concern? (required)

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? (required)

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? (required)

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? (required)

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

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Email (required)

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