Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download OTOLOGIC HISTORY Name: Date: Primary concern for today`s visit
Transcript
OTOLOGIC HISTORY Name: Primary concern for today’s visit: Date: How would you best describe your hearing? (More than one may apply) Hearing is fine with no concerns Able to hear but not clearly Difficulty hearing in noisy environments Difficulty hearing from a distance Difficulty hearing in group situations Not able to hear Have you previously had a diagnostic hearing test Yes How long ago? Results: Have hearing aids ever been recommended? Yes Worn? Which ear? Left Yes No How long have you used hearing aids? Age of current aids: Any concerns about current aids? No No Right Both Do you ever experience noises in either ear (ring, hissing, buzzing)? Yes No When did the sound begin? How frequently? Rarely Daily Occasionally Constantly (sound does not stop) Where? Right ear Left ear Both Can’t tell location Do you have a history of ear infection? When was your last infection? Yes No Have you ever had ear surgery? What type? Yes No Is there a family of hearing loss? Who? Yes No Why? Have you ever been exposed to loud noise, recently or in the past Firearms Factory work Military equipment Music Farm equipment Explosions Motorcycles/recreational vehicles Please mark the box if you have experienced any of the following: Excessive ear wax Ear drainage/bleeding Ear pressure/fullness Popping sensation in the ear Fluctuating hearing loss Fluid behind the eardrum Sensitivity to loud noises Other: Yes No Power tools Heavy equipment Swimmer’s ear Ear pain Dizziness/Vertigo Please mark the box if you have been diagnosed with any of the following: Otosclerosis Cholesteatoma Sudden hearing loss Labyrinthitis Meniere’s disease Barotrauma Permanent hearing loss Bell’s palsy Acoustic neuroma Ossicular dislocation/fixation Medical History Please mark the box if you have experienced any of the following: Heart disease Diabetes Stroke/TIA Meningitis Liver problems Cancer Mumps Measles Asthma Visual problems Long term IV antibiotics Mental Illness HIV/AIDS Tuberculosis Thyroid disease Exposure to chemicals/solvents High blood pressure Kidney or renal problems Environmental allergies Scarlet fever Radiation/chemotherapy Chronic sinus infections Loss of consciousness Please list your current prescriptions: Medication: Reason: 1. 2. 3. 4. 5. 6. **If needed please list additional medications on a separate piece of paper. ________________________________________________________________________________________________ Signature of person completing history _______________________________________________________________________________________________ Relationship to patient Date: Dr. Lisa Irby, Doctor of Audiology 432 S. Mustang Road, Suite B, Yukon, OK 73099 Phone: (405) 265-1133 Fax: (405) 265-1144 FOR INSURANCE FILING ONLY: Please provide Social Security # Primary insured name: Date of Birth: Employer: Please remember that insurance is considered a method of reimbursing the patient for fees paid to the physician, but is usually not designed to pay the entire fee. Because insurance companies vary in the amount they will pay for various services, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company (unless otherwise restricted by law or agreement we might have with insurer). IN ORDER TO HELP CONTROL THE COST OF BILLING, WE REQUEST PAYMENT FOR UN-COVERED SERVICES, CO-PAYMENTS AND DEDUCTIBLES BE MADE AT THE CONCLUSION OF YOUR VISIT UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR TO SERVICES BEING RENDERED. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other commercial insurance company, any information needed for this or a related claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits be sent to my physician. Regulations pertaining to Medicare assignment of benefits apply. Signature: _______________________________________ Date: ______________________________ Dr. Lisa Irby, Doctor of Audiology 432 S. Mustang Road, Suite B, Yukon, OK 73099 Phone: (405) 265-1133 Fax: (405) 265-1144
