Associated Audiologists, Inc Patient History
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- Brook Lucas
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3 Associated Audiologists, Inc Patient History Patient Name: DOB: Date: Primary Concern: When did your symptoms begin: List the outcomes you hope to achieve from today s appointment: Review of Systems & Conditions (please check all current or previous symptoms/conditions): Ear, Nose and Throat Hearing Loss Tinnitus Sound Sensitivity Dizziness / Vertigo Imbalance / Falls Ear Pain Ear Fullness / Pressure Ear Infections Ear Drainage Ear Drum Perforation Ear Trauma Ear Surgery Nasal Congestion Allergies Sinusitis Meniere s Disease Labyrinthitis Family History of Hearing Loss Eyes Vision Loss Glaucoma Double Vision Macular Degeneration Blindness Psychiatric Anxiety Depression Memory Loss Cognitive Changes Other: Neurological Peripheral Neuropathy Facial Numbness or Tingling Numbness in Hands or Feet Headaches / Migraines Seizures Tremors Head Injury Bell s Palsy Multiple Sclerosis Parkinson s Disease Alzheimer s Disease Stroke / TIA Insomnia Endocrine Diabetes Thyroid Disorder Hormone Therapy Musculoskeletal Decreased Range of Motion Decreased Fine Motor Skills Pain in Extremities Pain in Back or Neck Back or Neck Surgery Arthritis Cardiovascular Fainting Lightheadedness High / Low Blood Pressure Cardiovascular Surgery Pacemaker Previous Evaluations and Testing If yes, please list location and date: Hearing Evaluation: Tinnitus Evaluation: Vestibular Evaluation: Continued on Back Systemic and Other Allergies Measles Mumps Scarlet Fever Lyme Disease Syphilis Herpes Hepatitis HIV/AIDS Cytomegalovirus (CMV) Mononucleosis (Mono) Chicken Pox / Shingles Tuberculosis (TB) Meningitis Lupus Auto-Immune Disorder Kidney Disease Cancer Sickle Cell Anemia Integumentary Skin Lesions on the Ear Rashes or Spots on the Ear Genetic Disorders/Syndromes: Other Symptoms or Medical Conditions: ENT Evaluation: MRI or CT Scan: Other: 1/2016
4 Do you have a history of noise exposure? Yes or No If yes, please describe: Did you wear hearing protection during this exposure? Yes or No If yes, Type: List all current prescription and over-the-counter medications/supplements, or attach current list. Name Reason Dose Frequency How Often Route Oral, Injection, Topical, Etc How Long? Approx. Have you used tobacco in the past 24 months? Yes No If you have difficulty hearing/understanding, complete the following section: Hearing difficulty in Both Ears Right Ear Only Left Ear Only Does one ear seem worse than the other? When did you first notice difficulty hearing? Did it begin suddenly or gradually? Do you feel it has progressed? Y or N Do you have difficulty hearing in quiet environments? Y or N In noisy environments? Y or N If you have tinnitus, ringing or noise in your ears or head, complete this section: Tinnitus is present in Both Ears Right Ear Only Left Ear Only Does the tinnitus in one ear seem worse than the other? How long have you noticed your tinnitus? Did it begin suddenly or gradually? Is your tinnitus constant? Y or N Describe the sound you hear? If you have dizziness/imbalance, complete the following section: Describe your dizziness or imbalance When did these symptoms begin? Does anything trigger these symptoms? How many times have you fallen in the past 12 months? List any significant injuries from a fall: 1/2016
5 Associated Audiologists, Inc Hearing Case History If you have difficulty hearing or understanding complete the following questionnaire. Please do not skip questions. If you wear a hearing aid, answer according to how you hear with your hearing aid(s). No Sometimes Yes 1. Does your hearing cause you to feel embarrassed when you meet new people? 2. Does your hearing cause you to feel frustrated when talking to members of your family? 3. Do you have difficulty hearing or understanding co-workers, clients or customers? 4. Do you feel handicapped by a hearing problem? 5. Does your hearing cause you difficulty when visiting friends, relatives or neighbors? 6. Does your hearing cause you difficulty in theatres, church or public events? 7. Does your hearing cause you to have arguments with family members? 8. Does your hearing cause you difficulty when listening to the TV, radio or talking on the phone? 9. Do you feel that your hearing limits or hampers your personal or social life? 10. Does your hearing cause you difficulty when in a restaurant with relatives, friends or co-workers? TOTALS: If results indicate that amplification would be beneficial, are you motivated to proceed? Not Motivated Absolutely Motivated Rank these factors in order of importance (1-5, 1 most important, 5 least important) Hearing in Quiet Hearing in Noise Expense Cosmetics Durability Current hearing aid users please complete the following: How long have you worn hearing aid(s)? Do you wear 1 aid or 2? Current Make/Model? How old are current aids? How often do you wear your current hearing aids? What would you improve about your current hearing aids?
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Please list medications and dosage (including non-prescriptions) you are currently taking or have taken recently:
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Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Please arrive fifteen minutes early so that we may prepare your medical information for your visit. Allow about one and a half hours for your visit.
Dear New Patient, Thank you for choosing Ford Eye Center for your eye care needs. The doctors and staff look forward to introducing you to the benefits of quality eye care. Our team is devoted to making