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Audiological History Intake Form

Name(Required)
Date of Birth(Required)
Today's Date(Required)
Do you experience hearing loss?(Required)
If yes, which ear(s)?
Hav you ever seen an ENT physician?(Required)
Have you had a hearing test before?(Required)
History of ear surgery?(Required)
Do you currently wear hearing aids or have you ever worn hearing aids(Required)
Developmental Disorders? Delays?(Required)
Tinnitus (sounds in the ear)?(Required)
Ear Pain?(Required)
Ear Infections?(Required)
Ear Drainage?(Required)
Ear Wax Buildup?(Required)
Family History of Hearing Loss?(Required)
History of Noise Exposure?(Required)
Medical History: Please check any of the following that you currently have or have had in the past
This field is for validation purposes and should be left unchanged.