Patient Registration PATIENT INFORMATIONHow did you hear about Bryant Better Hearing? Insurance Physician Which Physician recommended us? Patient's Name* First Last Date of Birth* MM slash DD slash YYYY Parent's Name (if minor) First Last Email* Address* Mailling Address City State ZIP Home PhoneMobile PhoneWork PhoneGender Female Male Marital Status Single Married Widowed Divorced Emergency Contact Name First Last Emergency Contact PhonePHYSICIAN INFORMATIONFamily Physician Office PhoneOffice FaxOffice Address Street Address Address Line 2 City State ZIP PRIMARY INSURANCE INFORMATIONInsurance 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 MM slash DD slash YYYY Policyholder's Employer Does 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.* 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 HISTORYPrimary 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 HISTORYDo 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 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 Quiet 1 2 3 4 5 Television 1 2 3 4 5 Leisure Activities 1 2 3 4 5 Restaurants 1 2 3 4 5 Meetings/Groups 1 2 3 4 5 Work Place 1 2 3 4 5 Telephone 1 2 3 4 5 Church 1 2 3 4 5 Male Voices 1 2 3 4 5 Female Voices 1 2 3 4 5 Importance 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 Quiet 1 2 3 4 5 Television 1 2 3 4 5 Leisure Activities 1 2 3 4 5 Restaurants 1 2 3 4 5 Meetings/Groups 1 2 3 4 5 Work Place 1 2 3 4 5 Telephone 1 2 3 4 5 Church 1 2 3 4 5 Male Voices 1 2 3 4 5 Female Voices 1 2 3 4 5 TINNITUS HISTORYDo 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 AnnoyancePlease 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. 1 2 3 4 5 6 7 8 9 10 LoudnessPlease rate your tinnitus for annoyance on a scale of 1 to 10, with 0 being not loud and ten being extremely loud 1 2 3 4 5 6 7 8 9 10 DIZZINESS/VERTIGO HISTORYDo 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 LISTPlease list all medications here.Medication 1 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 2 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 3 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 4 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 5 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 6 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 7 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 8 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 9 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 10 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 11 Dosage (mg) Quantity per day Form (pill, injection, liquid, etc.) Medication 12 Dosage (mg) Form (pill, injection, liquid, etc.) Quantity per day ANY ADDITIONAL INFORMATION:CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
