Patient Information Form

Patient Full Name *

Date of birth *

Patient information, (Use parent/guardian information to complete reminder of this section if patient is under age of 18.)

Name of Responsible Party

Sex *

Male

Female

Phone Numbers *

Home Phone
Cell Phone

Cell Provider

Email Address *

Emergency Contact

Emergency Contact Phone Number

Relation to Patient

Primary Mailing Address

Secondary Address

Preferred method of contact

Text

Phone

Patient Occupation

Have you heard about JHC before?

Yes

Referred by

Have you considered other hearing aid providers? If so, who?

What is the reason for today's appointment?

First Time Hearing Evaluation

Shopping for Hearing Aids

Known hearing loss

Other

Does anyone in your family have hearing loss?

Yes

If so, who?

Reason for appointment

Hearing Heath Assessment

General Information

When was your last hearing exam?

By Whom?

How long ago did you start to notice a decline in your hearing?

Does anyone in your family have hearing loss?

Yes

Have you ever had any ear infections?

Yes

Have you ever had any ear surgery?

Yes

Do you hear noises/sounds in your head?

Yes

Are you on blood thinners?

Yes

List your top listening situations where you would like to hear better

Does having a hearing problem...

Make it difficult for you to converse on the phone?

Frequently

Sometimes

Never

Cause others to complain that you turn up the TV or radio too loud?

Frequently

Sometimes

Never

Cause you difficulty following a conversation in a restaurant?

Frequently

Sometimes

Never

Limit or hamper your social life?

Frequently

Sometimes

Never

Cause people to repeat themselves?

Frequently

Sometimes

Never

Difficulty hearing in the presence of background noise?

Frequently

Sometimes

Never

Difficulty hearing women’s or children’s voices?

Frequently

Sometimes

Never

You hear people, but don’t understand what they are saying?

Frequently

Sometimes

Never

Cause you to think other people mumble?

Frequently

Sometimes

Never

Cause you to feel stressed or tired when listening for long periods of time?

Frequently

Sometimes

Never

Please read carefully and sign below

I give permission to JHC to release information, verbal and written (contained in my medical record and other related information), to my insurance company, rehab nurse, case manager, attorney, employer, related health care providers, assignees and/or beneficiaries, and all other related persons, information without patient identifiers may be for quality purposes. I authorize JHC to use and release my protected health information, i.e., my contact information, for marketing related to hearing care products or services. I acknowledge that I have received and reviews the Health Insurance Portability & Accountability Act (HIPPA) policy of this office. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for professional services or purchase rendered. I have read all the information on this sheet, completed the answers, and certify this information is true and correct to the best of my knowledge, and I hereby give JHC permission to treat my concerns.

Patient/Guardian Signature

Clear