Confidential Patient History Please note: this online form is to be completed prior to an appointment and is highly secure. You can download and print a copy of this form by clicking here. Name First Last PhoneEmail Date of Birth MM slash DD slash YYYY Emergency Contact Name Emergency Contact PhoneHave you seen a doctor in the past six months? Yes No Doctor Name Are you hypertensive? Yes No Have a heart condition? Yes No Have diabetes? Yes No Do you have any other medical conditions? Yes No Please ExplainDo you take medication every day? Yes No What medication do you take?Have you seen a doctor specializing in diseases of the ear? Yes No Please give the date and by whomHave you ever had your hearing tested? Yes No Please give the date and by whomHave you ever had any type of ear surgery? Yes No What type of surgery and by whom?Deformity of the ear Yes No Drainage from the ear Yes No Sudden or rapid loss of hearing in the past 90 days? Yes No Acute or chronic dizziness Yes No Have you ever seen a doctor for wax removal? Yes No Do you ever have pain in your ears? Yes No Do you have trouble understanding conversation? Yes No Do you have trouble hearing in a crowd? Yes No Do you have trouble hearing on the telephone? Yes No Does anyone in your family have a hearing problem? Yes No Whom?Have you ever worn a hearing aid? Yes No Do you have ringing in your ears? Yes No Who referred you to us?