Please enable JavaScript in your browser to complete this form.Personal InformationName *Nickname or Preferred NameDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Home AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Email *Marital StatusMarriedWidowedSingleWith whom do we have your permission to share your hearing healthcare needs?With whom do we have your permission to share your hearing healthcare needs? *1. No One2. Only those persons listed belowGuest #1 Name *Guest #1 Phone Number *Guest #1 Relationship *Medical HistoryDoctor's Name & OrganizationDo we have your permission to send your doctor a copy of your audiogram? *YesNoHave you seen a doctor specializing in diseases of the ear? *NoYesHave you ever had any type of ear surgery? *NoYesWhat type of ear surgery did you have?When was your ear surgery?Are you allergic to latex gloves or alcohol?NoYesHave you ever had your hearing tested?NoYesWhat were the results of your hearing test?Do you have a history of ear infections? *NoYesAre you currently taking blood thinners? *NoYesPlease list to the best of your ability all medications you are taking or have been taking.We will be happy to photocopy your medication list if you have one.About Your HearingDo you hear conversation well in a quiet situation?YesNoDo you find it difficult to follow a conversation in a noisy restaurant?NoYesHow often are you in a crowd or in a noisy room? SometimesAlwaysNeverDo you find yourself asking people to speak up or to repeat themselves? YesNoDo you experience difficulty following dialog on television?YesNoDo others complain that the TV or radio is too loud? YesNoDo you hear better with one ear than the other? YesNoDo you sometimes find it difficult to understand a speaker at a public meeting or religious service? NoYesHave you had significant noise exposure at work or recreation? YesNoIs there a family history of hearing loss? YesNoDo your family and friends think you have a hearing loss? YesNoAbout Hearing AidsDo you wear hearing aids?YesNoWhat kind of hearing aids do you wear?How old are they?How many hours a day do you wear your hearing aids? Do your hearing aids make your ears feel "plugged up"? NoYesAre you aware of digital technology? NoYesHow did you hear about The Hearing Connection?FacebookDirect MailNewspaperYellow PagesFamily/FriendTelevisionGoogle SearchOtherHIPAA Acknowledgement and ConsentI understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: *Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. *Obtain payment from designated third-party payers. *Conduct normal health care operations such as quality assessments or evaluations, and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. I understand the HIPAA FormSignatureClear SignatureCaptcha * = NameSubmit