Patient Registration Form – Bryant Better Hearing

PATIENT INFORMATION

How did you hear about Bryant Better Hearing?

Insurance
Physician

Which Physician recommended us?

Patient's Name*

First Last

Date of Birth*

Parent's Name (if minor)

First Last

Email*

Address*

Mailling Address City State ZIP

Home Phone

Mobile Phone

Work Phone

Gender

Female
Male

Marital Status

Single
Married
Widowed
Divorced

Emergency Contact Name

First Last

Emergency Contact Phone

PHYSICIAN INFORMATION

Family Physician

Office Phone

Office Fax

Office Address

Street Address Address Line 2 City State ZIP

PRIMARY INSURANCE INFORMATION

Insurance Company

Policyholder's Name

Relationship to Patient

Parent
Guardian
Spouse
Self

Policyholder's ID#

Group ID#

Policyholder's Gender

Female
Male

Policyholder's Date of Birth

Policyholder's Employer

Does patient have

Medicaid
Secure Horizons
Medicare Coverage

Release of Medical Records / Assignment of Insurance Benefits

1) 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.*

Yes
No

2) I consent for Bryant Better Hearing Center to contact me regarding annual services, warranty renewals and any other special promotions.*

Yes
No

3) 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.*

Yes
No

I 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 HISTORY

Primary reason contacting Bryant Better Hearing?

Has a doctor examined you in the past 6 months?

Yes
No

Are you currently taking any medications?

Yes
No

Do you have:

Diabetes
Epilepsy
Heart Problems
HIV/AIDS
Hepatitis

Have you received chemotherapy treatment(s) or any other long-term drug treatment(s)?

Yes
No

If so, what and when?

Do you smoke?

Yes
No

If so, how many packs per day?

Will this be your first hearing test?

Yes
No

Have you ever had surgery?

Yes
No

If yes, what?

Do you have any of the following:

Deformity of the ear?

Yes
No

Sudden or rapid hearing loss in the past 90 days?

Yes
No

Acute or recurring dizziness?

Yes
No

Has your hearing in one ear worsened in the past 90 days?

Yes
No

Do you ever have ear pain?

Yes
No

Have you ever had wax removed from your ears by a doctor?

Yes
No

In which ear is your hearing the worst?

Right
Left
Same

Have you put any medications or other substances (baby oil, alcohol, hot wax) in your ears?

Yes
No

If so, what and when?

HEARING HISTORY

Do people seem to mumble?

Yes
No

Do you find yourself asking people to repeat what they have said?

Yes
No

Do you sometimes hear words but do not always understand them?

Yes
No

Do you find it difficult to hear in noisy places?

Yes
No

Have you been told that you speak loud?

Yes
No

Is it difficult to understand speech when your back is to the speaker?

Yes
No

Do others complain that you play the TV too loud?

Yes
No

Have you occasionally missed the ringing of a telephone?

Yes
No

Do you find it difficult to hear when using a telephone?

Yes
No

Do you avoid social events because of hearing difficulty?

Yes
No

How many years have you experienced hearing difficulty?

How did your hearing loss develop?

Suddenly
Gradually

Do you know the cause of your hearing loss?

Yes
No

Do you have a hearing instrument?

Yes
No

If a hearing loss is discovered, are you ready for help?

Yes
No

Do you have any history of noise exposure (loud music, gunfire, loud machinery/engines)?

Yes
no

Have you ever worn a hearing aid?

Yes
No

Does anyone in your family have hearing loss?

Yes
No

If so, who?

HEARING INSTRUMENT USER (While wearing hearing instrument)

Do you hear but have difficulty understanding?

Yes
No

Do you have difficulty understanding when two or more are talking?

Yes
No

Do you have difficulty understanding when in a crowd?

Yes
No

Do you have difficulty understanding at a distance?

Yes
No

Do you have difficulty knowing from which direction sounds are coming?

Yes
No

Do you have difficulty while using a telephone?

Yes
No

Does your own voice sound hollow and unnatural?

Yes
No

Do words often run together?

Yes
No

Do your hearing instrument(s) make sounds loud enough?

Yes
No

Are some sounds too loud?

Yes
No

Do your hearing instrument(s) make sounds tinny?

Yes
No

Do your hearing instrument(s) whistle?

Yes
No

Do your hearing instrument(s) make your ears sore?

Yes
No

HEARING DIFFICULTY QUESTIONNAIRE

Hearing Qualtiy

On a scale of 1 to 5. with 1 being POOR and 5 being NORMAL, rate your hearing quality in the following situations:

Conversation in Quiet

Television

Leisure Activities

Restaurants

Meetings/Groups

Work Place

Telephone

Church

Male Voices

Female Voices

Importance to You

On 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 Quiet

Television

Leisure Activities

Restaurants

Meetings/Groups

Work Place

Telephone

Church

Male Voices

Female Voices

TINNITUS HISTORY

Do you have any symptoms of tinnitus (ringing, buzzing, hissing)?

Yes
No

Which 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?

Right
Left
Both

When did it begin?

How frequently?

Constant
Intermittent
Daily
Hourly
Other

How long does it last?

Is it occurring today?

Yes
No

Does it pulse with your heartbeat?

Yes
No

Annoyance

Please 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.

Loudness

Please rate your tinnitus for annoyance on a scale of 1 to 10, with 0 being not loud and ten being extremely loud

DIZZINESS/VERTIGO HISTORY

Do you have dizziness or vertigo symptoms?

Yes
No

When did it begin?

How often does it occur?

How long do the episodes last?

Have you seen a physician regarding these symptoms?

Yes
No

If yes, when were you seen?

Who was the physician?

What was the treatment?

CURRENT MEDICATION LIST

Please list all medications here.

Medication 1

Dosage (mg)

Quantity per day