Patient Information. Medical History. Audiologic History

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1 Greenville, SC Patient Information Name Date of Birth Age Gender Male Female Employment Full Time Part Time Retired Referring Physician and/or PCP Send report to your physician? Yes No What is your primary reason for today s visit? Medical History How is your general health? Excellent Good Fair Poor Recent hospitalization or surgeries (please list) History of trauma to the head? Yes No Have you had radiation treatment to your head or neck? Yes No Do you have a pacemaker? Yes No Do you have diabetes? Yes No Present medications (please list) Are you on blood thinning medication? Yes No Audiologic History History of ear disease or infection? Yes No Youth Adulthood Ear surgery? Yes No Youth Adulthood Family history of hearing loss Yes No Youth Adulthood Do you have dizziness, vertigo, or loss of balance? Yes No Frequency: If yes, please describe: Duration: Nausea? Yes No Do you have tinnitus (ringing, buzzing, hissing)? Yes No Frequency Duration If yes, which ear? Right Left Both Do you have any ear pain or pressure? Yes No Right Left History of exposure to noise (recent or prior)? Yes No Type: Have you seen a hearing healthcare provider for your hearing before? Yes No If you have diagnosed hearing loss, have you ever been treated with hearing aids? Yes No Have you ever seen an Ears, Nose, and Throat physician for your hearing concern? Yes No Is your hearing better in one ear? Yes No Right Left Do you think your hearing is changing? Yes No Gradual Sudden Patient s Signature Date

2 Greenville, SC Hearing Profile Listening Environments: Please check the appropriate boxes for each condition below which apply to your current hearing abilities without hearing devices. One on one conversations Quiet Room (1 to 2 people) Small Groups (4 to 6 people) Restaurants Work (if applicable) Religious services Television On the Phone How well do you currently hear in this environment? If hearing loss was not a factor, how frequently would you be in this environment? Excellent Fair Poor Often Sometimes Rarely 1. What is your previous experience with hearing devices? (please select one) Never inquired before I have learned about them but have not tried I have tried them but returned them I have hearing device(s) and wear them occasionally I have hearing device(s) and wear them regularly If so, age of devices 2. How important to you are the following features in your hearing device(s)? (Please rank 1 to 4) Overall sound quality Reliability Style/Appearance Cost 3. On a scale of 1 to 10, how motivated are you to treat your hearing loss? (please circle one) Not Motivated Somewhat Motivated Motivated Very Motivated Extremely Motivated

3 Greenville, SC AUTHORIZATION FOR RELEASE OF INFORMATION I do hereby authorize Davis Audiology, LLC to furnish and/or to obtain information concerning with respect to patients physicians and manufacturers Signature Date Print Name If someone other than patient completing form: Relationship to Patient

4 Greenville, SC Davis Audiology s Financial Policy ASSIGNMENT OF INSURANCE BENEFITS Patients with insurance please read and sign below: Your insurance policy is a contract between you and your insurance company. We cannot guarantee payment of your claims or accept responsibility for negotiating claims with your insurance company. I hereby assign all medical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans to Davis Audiology. A photocopy of my Insurance card (assignment) and a copy of my driver s license are to be considered as valid as an original. I am financially responsible for all charges whether or not paid by the above insurance. I hereby authorize Davis Audiology to release all information necessary to secure the payment. If insurance pays only a portion of the bill or fails to make payment to Davis Audiology within 90 days, I will be responsible for payment of balance in full at that time. Patient s Name Signature Date MEDICARE PATIENTS: Patients with Medicare please read and sign below: I request payment of authorized Medicare benefits to be made to Davis Audiology for any services rendered. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or related services to pay the claim. If there are other insurance carriers, my signature authorizes releasing of information. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible for only the deductible, coinsurance and the non-covered services. Coinsurance and the deductible are based upon the charge determined by the Medicare carrier. Patient s Name Signature Date

5 Greenville, SC Acknowledgement of Receipt of Privacy Notice I hereby acknowledge that I received a copy of this medical practice s Notice of Privacy Practices. Signed: Date: If not signed by the patient, please indicate relationship: Disclosure of Medical Information Your medical information and communication of that information is essential to your care. We prefer to speak directly with each patient but we understand that other individuals or family members may have knowledge of and may be assisting in your care. Please list the individuals who we are authorized to discuss your care with. (Note: We cannot discuss your care with others, including your spouse or other family members living with you, unless they are listed below.) Name of person: Relationship to Patient Name of person: Relationship to Patient Confidential Communications between Office and Patients *Appointment Reminders: I prefer to be reminded of scheduled appointments by (complete all that apply) phone address *Messages: I authorize a message concerning scheduled appointments or treatment to be left on the following answering machine or voice mail (check all that apply) home phone work phone cell phone I do not authorize * s: I authorize communications through s concerning scheduled appointments, treatment, practice information and newsletters to be sent to the following address: Signature: Date:

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