Patient Registration PATIENT INFORMATIONHow did you hear about Bryant Better Hearing?InsurancePhysicianWhich Physician recommended us?Patient's Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Parent's Name (if minor) First Last Email* Address* Mailling Address City State ZIP Home PhoneMobile PhoneWork PhoneGenderFemaleMaleMarital StatusSingleMarriedWidowedDivorcedEmergency Contact Name First Last Emergency Contact PhonePHYSICIAN INFORMATIONFamily PhysicianOffice PhoneOffice FaxOffice Address Street Address Address Line 2 City State ZIP PRIMARY INSURANCE INFORMATIONInsurance CompanyPolicyholder's NameRelationship to PatientParentGuardianSpouseSelfPolicyholder's ID#Group ID#Policyholder's GenderFemaleMalePolicyholder's Date of Birth Date Format: MM slash DD slash YYYY Policyholder's EmployerDoes patient have Medicaid Secure Horizons Medicare Coverage Release of Medical Records / Assignment of Insurance Benefits1) In order to ensure proper follow-up and continuity of care, I agree that a copy of my medical record may be released to my physician, a designated referral physican, and/or the provider, if any, who referred me here.*YesNo2) I consent for Bryant Better Hearing Center to contact me regarding annual services, warranty renewals and any other special promotions.*YesNo3) I consent to be examined by the Audiologists/Practitioners at Bryant Better Hearing Center at each visit and request that payment of authorized benefits be made to Insta-Sound, Inc. on my behalf, for any services provided to me or my dependent. I authorize any holder of medical and other information about me to release to Medicare and its agents, any insurance carrier, any other third party payer, state medical assistance agency, or any other governmental or private payer responsible for any changes incurred regardless of any problems, which may arise with my insurance carrier. All charges, whether or not paid by my insurance carrier and a forty percent (40%) charge for all debt collection, will apply if needed. I authorized the use of this signature on all insurance claims submissions and a copy of this authorization to be used in place of its original.*YesNoI acknowledge that I have read and fully understood the questions above, and I understand that this will serve as my digital signature.* I agree MEDICAL HISTORYPrimary reason contacting Bryant Better Hearing?Has a doctor examined you in the past 6 months?YesNoAre you currently taking any medications?YesNoDo you have: Diabetes Epilepsy Heart Problems HIV/AIDS Hepatitis Have you received chemotherapy treatment(s) or any other long-term drug treatment(s)?YesNoIf so, what and when?Do you smoke?YesNoIf so, how many packs per day?Will this be your first hearing test?YesNoHave you ever had surgery?YesNoIf yes, what?Do you have any of the following:Deformity of the ear?YesNoSudden or rapid hearing loss in the past 90 days?YesNoAcute or recurring dizziness?YesNoHas your hearing in one ear worsened in the past 90 days?YesNoDo you ever have ear pain?YesNoHave you ever had wax removed from your ears by a doctor?YesNoIn which ear is your hearing the worst?RightLeftSameHave you put any medications or other substances (baby oil, alcohol, hot wax) in your ears?YesNoIf so, what and when?HEARING HISTORYDo people seem to mumble?YesNoDo you find yourself asking people to repeat what they have said?YesNoDo you sometimes hear words but do not always understand them?YesNoDo you find it difficult to hear in noisy places?YesNoHave you been told that you speak loud?YesNoIs it difficult to understand speech when your back is to the speaker?YesNoDo others complain that you play the TV too loud?YesNoHave you occasionally missed the ringing of a telephone?YesNoDo you find it difficult to hear when using a telephone?YesNoDo you avoid social events because of hearing difficulty?YesNoHow many years have you experienced hearing difficulty?How did your hearing loss develop?SuddenlyGraduallyDo you know the cause of your hearing loss?YesNoDo you have a hearing instrument?YesNoIf a hearing loss is discovered, are you ready for help?YesNoDo you have any history of noise exposure (loud music, gunfire, loud machinery/engines)?YesnoHave you ever worn a hearing aid?YesNoDoes anyone in your family have hearing loss?YesNoIf so, who?HEARING INSTRUMENT USER (While wearing hearing instrument)Do you hear but have difficulty understanding?YesNoDo you have difficulty understanding when two or more are talking?YesNoDo you have difficulty understanding when in a crowd?YesNoDo you have difficulty understanding at a distance?YesNoDo you have difficulty knowing from which direction sounds are coming?YesNoDo you have difficulty while using a telephone?YesNoDoes your own voice sound hollow and unnatural?YesNoDo words often run together?YesNoDo your hearing instrument(s) make sounds loud enough?YesNoAre some sounds too loud?YesNoDo your hearing instrument(s) make sounds tinny?YesNoDo your hearing instrument(s) whistle?YesNoDo your hearing instrument(s) make your ears sore?YesNoHEARING DIFFICULTY QUESTIONNAIREHearing QualtiyOn a scale of 1 to 5. with 1 being POOR and 5 being NORMAL, rate your hearing quality in the following situations:Conversation in Quiet12345Television12345Leisure Activities12345Restaurants12345Meetings/Groups12345Work Place12345Telephone12345Church12345Male Voices12345Female Voices12345Importance to YouOn a scale of 1 to 5. with 1 being NOT IMPORTANT and 5 being VERY IMPORTANT, rate how important the following situations are to you.Conversation in Quiet12345Television12345Leisure Activities12345Restaurants12345Meetings/Groups12345Work Place12345Telephone12345Church12345Male Voices12345Female Voices12345TINNITUS HISTORYDo you have any symptoms of tinnitus (ringing, buzzing, hissing)?YesNoWhich sound(s) do you hear? Ringing Buzzing Hissing Crickets Other Is it any of the following? (Check all that apply) Roaring Rushing Wooshing Which ear?RightLeftBothWhen did it begin?How frequently? Constant Intermittent Daily Hourly Other How long does it last?Is it occurring today?YesNoDoes it pulse with your heartbeat?YesNoAnnoyancePlease rate your tinnitus for annoyance on a scale of 1 to 10, with one being not bothersome and ten being extremely bothersome and unable to function normally.12345678910LoudnessPlease rate your tinnitus for annoyance on a scale of 1 to 10, with 0 being not loud and ten being extremely loud12345678910DIZZINESS/VERTIGO HISTORYDo you have dizziness or vertigo symptoms?YesNoWhen did it begin?How often does it occur?How long do the episodes last?Have you seen a physician regarding these symptoms?YesNoIf yes, when were you seen?Who was the physician?What was the treatment?CURRENT MEDICATION LISTPlease list all medications here.Medication 1Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 2Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 3Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 4Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 5Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 6Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 7Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 8Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 9Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 10Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 11Dosage (mg)Quantity per dayForm (pill, injection, liquid, etc.)Medication 12Dosage (mg)Form (pill, injection, liquid, etc.)Quantity per dayANY ADDITIONAL INFORMATION:CAPTCHAEmailThis field is for validation purposes and should be left unchanged.