PATIENT INFORMATION. Soc. Sec. #: First Initial Last. Name Relationship Phone Number. Employer. Occupation
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1 Patient s Name Residence Address Mailing/Temporary Address Home Phone Best day time contact? Home Cell Work PATIENT INFORMATION Soc. Sec. #: First Initial Last. and Street City State Zip Code. and Street City State Zip Code Cell Phone Work Phone Sex Age Birthdate / / Marital Status: Emergency Contact Spouse s Name Referred by Name Relationship Phone Number Primary Care Physician IF PATIENT IS A CHILD, GIVE NAMES OF BOTH PARENTS OR LEGAL GUARDIANS BELOW Father s Name Day Time Contact Number Mother s Name Day Time Contact Number INSURANCE INFORMATION (Please bring insurance cards with you.) Primary Insurance Insured s Name Secondary/Supplemental Insurance Insured s Name I.D. Number Insured s DOB I.D. Number Insured s DOB Patient s Signature Date
2 PATIENT CASE HISTORY FORM Name: PERMISSION TO RELEASE DOB: RECORDS GENERAL HISTORY What is your primary reason for coming in today? If you suspect a hearing loss, how long have you noticed this problem? What do you feel is the cause of your hearing loss? Was the onset gradual or sudden? Have you ever had a hearing test? If yes, when? In which ear do you hear the best? Right Left Same in both ears How does your hearing difficulty affect your daily life? EAR, HEARING & NOISE EXPOSURE HISTORY (please circle the appropriate answer and provide more information where necessary) Known Hearing Loss? Tinnitus (ringing/other noises in ears)? *If yes, please fill out the Tinnitus Questionnaire. How long? Dizziness/Balance problems? Past Ear Surgery? Does the room spin? How long have you had problems? How frequently does it occur? Ear Pain within the last 90 days? Duration of an episode? Family History of Hearing Loss? Who? Ear Drainage within the last 90 days? History of noise exposure? Military? Other: Full/plugged sensation? isy Hobbies: Firearm use? Loud music/concerts? Other: How much difficulty do you have hearing in the following situations? Difficulty Some Difficulty Frequent Difficulty t Relevant One to one conversation: Conversation in small groups (3-6 people): Conversation in large groups (7+ people): Outdoors: Concert/movie: Place of worship/lectures: Restaurant/café: Watching TV: In a car: Workplace: Telephone: Landline Cellular Other (specify):
3 MEDICAL HISTORY Have you ever had any of the following: Arthritis Diabetes Type I Mumps Allergies Pacemaker Diabetes Type II Bell s Palsy Hepatitis Parkinson s High Blood Pressure Scarlet Fever High Fevers Seizures Concussion/Skull Fracture Measles HIV/AIDS Stroke/TIA Dementia/Alzheimer s Meningitis Tuberculosis Depression/Anxiety Multiple Sclerosis Macular Degeneration Headaches Blood Disorders Heart Trouble Kidney Disease Oxygen Use Cancer (Type: Treatment: ) Do you have frequent MRI s? Is there any other information related to your hearing you feel might be important for the Provider to know? MEDICATION HISTORY Certain medications can affect your hearing health, resulting in hearing loss, ringing in the ear, or balance disorders. Please list ALL prescription and over the counter medications OR provide a medications list if you already have one. Name of Medications Dosage Taken How Often? Taken for What? Route (Pill or IV) Do you use tobacco products? Are you allergic to any medications? Please list: Are you allergic to any adhesives or plastics? Any history of chemotherapy or radiation treatment? If yes, please explain: HEARING AID HISTORY Have you ever worn a hearing aid? Do you currently use a hearing aid? If yes, how long have you had a hearing aid? In which ear do you use a hearing aid? Right Left Both Do you wear the hearing aid(s) regularly? Do you feel you need hearing aid(s)? Any comments about your hearing aid use? If new hearing aids are recommended, how important are the following factors? (Please rank them 1 to 4 with 1 being most important) Overall sound quality Ease of use Style/Appearance Cost How motivated are you regarding doing something about your hearing loss? (Please choose one) t Motivated Somewhat Motivated Motivated Very Motivated Extremely Motivated Reviewed by:
4 PATIENT RELEASE FORM Patient Name: PERMISSION TO RELEASE RECORDS Date of Birth: Please review each of the items below and initial next to each item indicating that you have read and understand each item. Please sign and date the bottom of the page. Do not initial the items that do not apply to you. If you have any questions please ask one of our staff. PERMISSION TO RELEASE RECORDS: We provide you with important diagnostic information about your hearing. We feel it is important for your physician to have this information for your medical records. By signing this form you are providing us permission to send a copy to your physician. This release will be in effect until we receive a written notice from you requesting that we may no longer forward this information. PERMISSION TO OBTAIN RECORDS: In order to provide you with the best service possible, we may be required to contact your previous audiologist, hearing aid dispenser, or hearing aid manufacturer for information regarding your hearing, hearing aid information, warranty, etc. This release will be in effect until we receive a written notice from you requesting that we no longer obtain this information. We will not be requesting personal medical information from a physician without a separate consent. ASSIGNMENT OF INSURANCE BENEFITS: Your insurance policy is a contract between you and your insurance company. We cannot guarantee payment of your claim or accept responsibility for negotiating claims with your insurance company. As a courtesy, we will be happy to help you determine the coverage you have available. We will also provide the billing services and make every effort to obtain the benefits for covered services. I hereby assign all medical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans to Tustin Hearing Center and/or Janell D. Reid, M.A. A photocopy of my insurance card and a copy of my driver s license are to be considered as valid as an original. FINANCIAL RESPONSIBILITY: I am financially responsible for all charges whether or not paid by the above insurance. I hereby authorize Tustin Hearing Center to release all information necessary to secure the payment. If insurance pays only a portion of the bill or fails to make payment to Tustin Hearing Center within 90 days, I will be responsible for payment of balance in full at that time. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT (HIPAA): By signing this form, you acknowledge receipt of the tice of Privacy Practices of Tustin Hearing Center. Our tice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our tice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our office at (714) I acknowledge receipt of the tice of Privacy Practices of Tustin Hearing Center. Patient or Guardian s Signature:
5 Mission Statement: To provide a REMARKABLE experience for our patients by exceeding the expectations through exceptional service, expertise and technology. What makes Tustin Hearing Center different Over 26 years of practice in the community Helped over 15,000 patients Full access to our experienced Audiologists and Audiology Assistants Fellows of the American Academy of Audiology Walk-in hours for troubleshooting and repairs Monday-Friday from 1:00 pm 2:00 pm Wide range of hearing aid options from one of our top-tier manufacturers Accept all types of insurance Financing options including Care Credit and Wells Fargo Centrally located in a state-of-the-art facility Convenient parking Follow-up appointments and routinely updated hearing tests Friendly, personable staff who is here for you Tustin Hearing Center Newport Avenue Medical Plaza Newport Ave., Ste. 101 Tustin, CA T: F:
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