HEARING & BALANCE QUESTIONNAIRE
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- Samson Griffith
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1 HEARING & BALANCE QUESTIONNAIRE Name Age Date of Birth Date I. DIZZINESS: The following questions refer to your dizziness. If you are not experiencing dizziness, please skip to the next section. Please describe in your own words the sensation you feel without using the word dizzy. Is your dizziness more a lightheadedness or a spinning? (Please circle one) Is your dizziness intermittent or is it constant? (Please circle one) When you experience intermittent dizziness, does it last seconds minutes hours days weeks? (Please circle one) When you experience intermittent dizziness, does it come on only when moving or even if perfectly still? (Please circle one) The following refer to a typical dizzy spell. Please answer them as yes or no and fill in the blanks.!! Do the dizzy spells come in attacks? If yes, how often? how long do they last? How long have you been experiencing them?!! Are you free of dizziness between attacks?!! Does your hearing change with an attack? Which ear?!! Are you dizzy mainly when you sit up or stand up quickly?!! Are you more dizzy in certain positions? Which positions?!! Are you nauseated during an attack?!! Are you dizzy even when lying down?!! Did you have a cold or flu just before the dizziness started?!! Do you notice fullness, pressure or ringing in your ears? Which side?!! Have you had pain or discharge in your ear recently? Which side?!! Have you had difficulty walking in the dark?!! Are you better if you sit or lie perfectly still? The following refer to other sensations you have. Please answer them as yes or no and fill in the blanks.!! Do you black out or faint when dizzy? Have you had:!! Severe or recurrent headaches?!! Any double or blurry vision?!! Numbness in your face or extremities?!! Weakness or clumsiness in arms, legs?!! Tingling around your mouth?!! Spots before your eyes?!! Jerking of arms or legs?!! Seizures?!! Confusion or memory loss?!! Recent head trauma? If yes, please explain!! Do you have a lightheaded or a swimming sensation when you are dizzy?!! Do you find yourself breathing faster or deeper when you are dizzy?!! Did you recently change your eyeglasses?!! Do you ever notice weakness or faintness a few hours after eating?!! Have any medicines been helpful in reducing the dizziness? Please list.
2 Colorado Springs Ear Associates II. HEARING LOSS: The following questions refer to your hearing loss. If you are not experiencing hearing loss, please skip. Please describe in your own words, the problem you are experiencing with your hearing. Did you notice your hearing loss suddenly or gradually? (Please circle one) Is your hearing loss intermittent or constant? (Please circle one) Is the hearing loss noticeable in the right left both? (Please circle one) How long have you noticed your hearing loss? The following refer to your hearing loss. Please answer them as yes or no and fill in the blanks.!! Do other younger family members have a known hearing loss?!! Older family members?!! Have you ever experienced a noise loud enough to cause your ear to ring?!! Do you shoot guns? If so, do you use ear protection?!! Is your work environment very noisy? If yes, please explain!! Was there a specific event that you feel caused your hearing loss? If yes, please explain!! Have you had any previous ear infections?!! Have you had any previous ear trauma?!! Do you notice difficulty hearing in crowds?!! Do you wear hearing aids? If yes, are you satisfied with them!! Have you ever had ear surgery? If yes, please list III. EAR RINGING (TINNITUS): The following questions refer to your tinnitus. If you are not experiencing tinnitus, please skip. Please describe in your own words, the problem you are experiencing with ear ringing. Did you notice your tinnitus suddenly or a gradually? (Please circle one) How long have you noticed it? Is your tinnitus intermittent or constant? (Please circle one) Is the tinnitus noticeable in the right left both In head? (Please circle one) Circle the best description(s) of your tinnitus: Ring Sizzle Hiss Hum Crackle Crickets Static Motor Ocean Transformer line Waterfall Popping Heartbeat Clicking On a scale of 0 10, please circle the loudness of your tinnitus (0 can t hear it, 10 very loud): The following refer to your tinnitus. Please answer them as yes or no and fill in the blanks.!! Does the tinnitus keep you awake at night?!! Did the tinnitus start after:!! Beginning a new medication? If so, which medicine!! Exposure of an intense sound? If so, please explain!! Head or neck injury? If so, please explain!! Infection of the ear or sinus?!! Do you feel irritable because of your tinnitus?!! Does your tinnitus interfere with your overall enjoyment of life?!! Is the tinnitus louder after eating salty foods or drinking caffeinated beverages?
3 MEDICAL QUESTIONNAIRE MEDICAL HISTORY: Check any medical problems you have been or are being treated for (include year of diagnosis).! High Blood Pressure! Visual loss! Psychiatric problems! Head injury! Heart Disease! Migraines! Arthritis! Neck injury! Heart Attack! Anemia! Thyroid problems! Joint replacements! Irregular heart beat! Cancer! Radiation to head/neck!! Seizures! Diabetes! Asthma/COPD!! Stroke! Brain tumors! Allergies/Sinus! How would you rate your overall health? Excellent Good Fair Poor SURGICAL HISTORY: Please note all the surgeries & procedures you have had (include year of surgery).! Tonsils & Adenoids! Stapedectomy! Tympanoplasty!! Ear tubes! Ossiculoplasty! Mastoidectomy! OTOLOGIC HISTORY: Please check if you have had exposure to any of the items below (include year of exposure).! Excessive noise (explain)! Meningitis! Gun shooting! High doses of aspirin or Motrin! Prolonged IV antibiotics (Gentamycin, Vancomycin)! Quinine for malaria! Cancer chemotherapy! Head injury SOCIAL HISTORY: What is your current occupation? Do you smoke? No Yes packs/day year quit Do you drink alcohol? No Yes drinks/week (type of alcohol used) Do you use caffeine? No Yes cups/day (coffee, tea, soda) Are you currently disabled? No Yes Reason for disability ALLERGIES TO MEDICATIONS: Please state the reaction you have had to each medicine MEDICATIONS: Please give us a complete list of all the medicine you take (please include strength and how often it is taken) FAMILY HISTORY: Check if any blood relative has had any of the following. Indicate which relative.! Ear deformities! Kidney failure! Diabetes! Bleeding! Meniere s Disease! Migraines! Blindness! Anesthesia reactions! Seizures! Thyroid problems! Total deafness! High Blood Pressure! Stroke! Cancer! Hearing loss!
4 Colorado Springs Ear Associates SYSTEM REVIEW (Next Page): Please check conditions that apply to your current health: GENERAL!! Fever!! Weight Loss!! Decreased Appetite!! Excessive Fatigue EYES!! Wear Glasses!! Glaucoma!! Cataracts!! Infections!! Injuries EAR, NOSE, THROAT, MOUTH!! Wear hearing aids!! Nose bleeds!! Congestion!! Inability to smell!! Sinus!! Sinus headaches!! Sore throat!! Mouth sores!! Hoarseness!! Difficulty swallowing CARDIOVASCULAR!! Chest pain/angina!! High blood pressure!! Irregular pulse!! Heart murmur!! High cholesterol!! Swelling hands/feet!! Leg pain while walking!! Pacemaker PSYCHIATRIC!! Depression!! Anxiety!! Mental Illness!! Sleeping difficulty ENDOCRINE!! Diabetes!! Thyroid disease!! Hormone problems!! Increased thirst/urination!! Increased appetite RESPIRATORY!! Asthma!! Emphysema!! Bronchitis!! Chronic cough!! Shortness of breath!! Pneumonia!! Bloody sputum!! Lung cancer!! Tuberculosis Date of last chest x-ray GASTROINTESTINAL!! Regular nausea/vomiting!! Blood in vomit!! Heartburn!! Gallbladder problems!! Hernia!! Abdominal pain!! Ulcer / gastritis!! Change in bowel habits!! Liver disease!! Jaundice!! Diverticulitis!! Irritable bowel/colitis!! Hemorrhoids!! Colon cancer GENITOURINARY!! Urinary tract infection!! Painful urination!! Blood in urine!! Loss of bladder control!! Kidney stones!! Sexually transmitted disease Males!! Prostate problems Females!! Menstrual flow / irregular!! Menopause!! Uterine/Cervical cancer!! Breast pain!! Use birth control Type of oral contraceptive Date of last PAP Date of last mammogram ALLERGIC/IMMUNOLOGIC!! Food allergies!! Inhalant allergies!! Immune disorders HEMATOLOGICAL/LYMPHATIC!! Anemia!! Bleeding tendencies!! Phlebitis!! Enlarged lymph nodes!! Blood transfusion When? MUSCULOSKELETAL!! Back/neck pain!! Arm/leg pain!! Joint pain/swelling!! Arthritis!! Broken bones!! Osteoporosis INTEGUMENTARY!! Skin disease/type!! Rashes/Where NEUROLOGICAL!! Fainting/blackout spells!! Seizures!! Memory problems!! Disorientation/confused!! Concentration problems!! Difficulty with speech!! Double/blurred vision!! Facial weakness!! Headaches!! Stroke!! Muscle weakness!! Numbness/tingling!! Tremors/hand shaking!! Eat salty foods!! Add salt to your food!! Eat out frequently!! Drink coffee, tea, sodas!! Drink alcohol!! Smoke cigarettes!! Exercise regularly Type?!! Other Medical problems!! Living Will!! Advanced Directives Patient Signature Date Physician Signature Date reviewed
5 Financial Policy & Privacy Practices 1. Patient with Insurance. You are responsible for deductibles, co-pays, non-covered services, coinsurance and items considered not medically necessary by your insurance company. Please pay co-payment and coinsurance amounts as services are rendered. The remaining balance should be taken care of 30 days after receipt of payment from the insurance company. If you or your insurance carrier makes payment exceeding your balance, reimbursement will be remitted. 2. Patient without Insurance (private pay). Please make payment for your care at each patient visit. 3. Worker s Compensation Patient. As a Worker s Compensation patient, you may be covered by insurance if your injury is reported at work and verified with your employer. Please be sure to inform the office personnel that injury resulted during employment. The patient is ultimately responsible for the balance due. 4. Medicare. Our office will submit your Medicare charges to Medicare and your secondary insurance, if applicable. You are responsible for deductibles, co-pays, and any non-covered services. Guarantee of Payment 1. I understand that I am totally responsible for payment of all fees and services rendered, irrespective of insurance coverage or other responsibilities. NOTE: The guarantor of each account is ultimately responsible for payment in full of the account. As a courtesy to you, we will bill your primary insurance. If insurance does not pay in a timely manner (within 90 days from the date of service and insurance filing), the insured will be expected to pay the balance and then pursue reimbursement from their insurance company. 2. I have been advised that if my health insurance carrier / HMO / Medicaid / Medicare plan claims that the services I received today are not considered reasonable and medically necessary for my care, I will be responsible for payment of these services. 3. I understand that if I am participating in an HMO plan, my primary care physician (PCP) must authorize the services that I requested and received today. I have been advised that if I did not notify my PCP in advance for a referral authorization, my HMO plan may deny payment for services and thus, I will become responsible for payment of all services. 4. I understand there is a $25 fee for any returned check for NSF (Non-sufficient funds). Assignment 1. I assign the benefits from my insurance carriers to this office for the medical/surgical benefits I am entitled. 2. I request that payment of authorized Medicare benefits be made on my behalf to Colorado Springs Ear Associates (CSEA) for any service furnished to me by these providers. Release of Information 1. I authorize CSEA to release to my insurance carrier(s) any information needed to determine benefits or benefits payable for related services. 2. I authorize CSEA to release any information in the course of my evaluation and treatment to my Primary Care Physician. 3. I authorize any physician, hospital, laboratory or x-ray facility to release to CSEA any and all medical information, hospital records, laboratory studies or x-rays that may be requested. A copy of this authorization is as binding as the original. Acknowledgement of Receipt of Privacy Practices I have reviewed a copy of Privacy Practices (HIPPA) for CSEA (Please initial). I authorize a representative of CSEA to discuss my private health information with the following person (Please initial): Name Relationship Name Relationship X Patient Signature Date Patient Name (please print) Person signing on behalf of patient (state relationship)
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Oakland Orthopedic Partners, P.C., offices of Bruce T. Henderson Paul C. Lewis 44555 Woodward Ave., Ste 406 & 407 Pontiac, MI 48341 Office 248.334.0524 Fax 248.858.3887 www.oaklandorthopedic.com Patient
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:
Eastside Medical Group: DATE: Name: Date of Birth: _Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here: SOCIAL HISTORY Marital Status: Single Married Partner Divorced Widow/Widower
PATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
Medical History Form
MAIN SATELLITE 49 Veronica Avenue Suite 202 901 West Main Street Suite 203 Somerset, NJ 08873 Freehold, NJ 07728 P: 732 640 5316 P: 732 640 5327 F: 800 689 2361 F: 800 689 2361 128 Rehill Avenue Suite
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:
Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:
Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social
Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
Patient Information (please print cleary)
Patient Information (please print cleary) Patient Name Male Date of Birth (mm/dd/yy) Social Security Number Female Address City State Zip Code Home Phone Number Cell Phone Number Email Address Employer
PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:
NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our