Park West

(865) 693-6065 ext. 1125

Fort Sanders

(865) 693-6065 ext. 1280

Lenoir City

(865) 292-3560

Tellico Village

(865) 693-6065 ext. 1270

Park West

(865) 693-6065 ext. 1125

Fort Sanders

(865) 693-6065 ext. 1280

Lenoir City

(865) 292-3560

Tellico Village

(865) 693-6065 ext. 1270

Park West

(865) 693-6065 ext. 1125

Fort Sanders

(865) 693-6065 ext. 1280

Lenoir City

(865) 292-3560

Tellico Village

(865) 693-6065 ext. 1270

Confidential Patient History

Please note: this online form is to be completed prior to an appointment and is highly secure.

Download and print a copy of this form

Confidential Patient History

Please note: this online form is to be completed prior to an appointment and is highly secure.

Download and print a copy of this form

Confidential Patient History

Please note: this online form is to be completed prior to an appointment and is highly secure.

Download and print a copy of this form

First Name

Last Name

Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Have you seen a doctor in the past six months?

Are you hypertensive?

Have a heart condition?

Have diabetes?

Do you have any other medical conditions?

Do you take medication every day?

Have you seen a doctor specializing in ear diseases?

Have you ever had your hearing tested?

Have you ever had any type of ear surgery?

Deformity of the ear

Drainage from the ear

Sudden or rapid loss of hearing in the past 90 days?

Acute or chronic dizziness

Have you ever seen a doctor for wax removal?

Do you ever have pain in your ears?

Do you have trouble understanding conversation?

Do you have trouble hearing in a crowd?

Do you have trouble hearing on the telephone?

Does anyone in your family have a hearing problem?

Have you ever worn a hearing aid?

Do you have ringing in your ears?

Who referred you to us?

First Name

Last Name

Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Have you seen a doctor in the past six months?

Are you hypertensive?

Have a heart condition?

Have diabetes?

Do you have any other medical conditions?

Do you take medication every day?

Have you seen a doctor specializing in ear diseases?

Have you ever had your hearing tested?

Have you ever had any type of ear surgery?

Deformity of the ear

Drainage from the ear

Sudden or rapid loss of hearing in the past 90 days?

Acute or chronic dizziness

Have you ever seen a doctor for wax removal?

Do you ever have pain in your ears?

Do you have trouble understanding conversation?

Do you have trouble hearing in a crowd?

Do you have trouble hearing on the telephone?

Does anyone in your family have a hearing problem?

Have you ever worn a hearing aid?

Do you have ringing in your ears?

Who referred you to us?

First Name

Last Name

Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Have you seen a doctor in the past six months?

Are you hypertensive?

Have a heart condition?

Have diabetes?

Do you have any other medical conditions?

Do you take medication every day?

Have you seen a doctor specializing in ear diseases?

Have you ever had your hearing tested?

Have you ever had any type of ear surgery?

Deformity of the ear

Drainage from the ear

Sudden or rapid loss of hearing in the past 90 days?

Acute or chronic dizziness

Have you ever seen a doctor for wax removal?

Do you ever have pain in your ears?

Do you have trouble understanding conversation?

Do you have trouble hearing in a crowd?

Do you have trouble hearing on the telephone?

Does anyone in your family have a hearing problem?

Have you ever worn a hearing aid?

Do you have ringing in your ears?

Who referred you to us?

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Latest Hearing Health News

Check out our Latest and Greatest section, together with hearing health professionals and industry experts

View All Articles

A Fifty-Year Journey to Better Hearing: Rich's Story of Taking the Next Step

Better hearing begins with one decision.

Why the Right Expert Matters: Susan's Success Story at PHC Tennessee

May Is Better Hearing and Speech Month.

Proactive Power: Why Evelyn Ann Is Proud to Prioritize Her Hearing

Every journey to better hearing starts with a single step: a decision to put yourself first.

Latest Hearing Health News

Check out our Latest and Greatest section, together with hearing health professionals and industry experts

View All Articles

A Fifty-Year Journey to Better Hearing: Rich's Story of Taking the Next Step

Better hearing begins with one decision.

Why the Right Expert Matters: Susan's Success Story at PHC Tennessee

May Is Better Hearing and Speech Month.

Proactive Power: Why Evelyn Ann Is Proud to Prioritize Her Hearing

Every journey to better hearing starts with a single step: a decision to put yourself first.