Client Intake Form

Please take a few minutes to fill in our intake form. This will speed up your intake in the office and will give us a chance to prepare before we meet with you.

First Name

Last Name

Phone

Street Address

City

Province

Postal Code

Family Doctor

Do you feel you have any hearing loss?

Was your hearing loss gradual or sudden?

Do you have any ringing or other sounds in your ears?

Is the ringing constant or occasional?

Is it only in one ear or both?

Do you experience any dizziness or vertigo?

Do you have any pain in your ears?

Do you suffer from frequent ear infections?

Have you ever had ear surgery?

Have you had any exposure to loud noise?

Occupational or recreational exposure to loud noise?

For how many years?

Have you ever had serious head injury?

Are you on any medications?

Have you ever seen an Ear-Nose-Throat Specialist?

Do you feel one of your ears is better than the other?

Do you have difficulty understanding speech?

Do you have family members with hearing loss?

Have you had a hearing evaluation in the past?

Have you ever worn hearing aids before?

How did you hear about us?

Please add anything that you feel might be helpful: