Brown Hearing Centers: Personal Information

Brown Hearing Centers
Where Technology Meets Tradition Since 1962
Welcome to Brown Hearing Centers, we want to provide excellent hearing care to you. Please tell
us a little about yourself by completing as much as possible on both sides of this form.
How did you hear about us?______________________________________________________
PERSONAL INFORMATION:
PATIENT'S NAME_____________________________________________________________________________
FIRST MIDDLE LAST
MAILING ADDRESS__________________________________________________________________________
CITY STATE ZIP
911 ADDRESS IF DIFFERENT___________________________________________________________________

CITY STATE ZIP
TELEPHONE (HOME) _________________________________ (WORK)________________________________
BIRTHDATE____________ AGE_______ MALE____ FEMALE____ MARITAL STATUS ___________
FULL NAME AND PHONE NUMBER OF PRIMARY CARE PHYSICIAN __________________________________
NAME & TELEPHONE OF NEAREST RELATIVE____________________________________________________
EMAIL ADDRESS: _________________________________ May we contact you via email? YES_____ NO ____
INSURANCE INFORMATION - PLEASE READ AND SIGN/INITIAL:
DISCLAIMER: As a professional courtesy, we will submit your claim to your insurance provider, but this
does not guarantee their payment. You accept responsibility for co-pay, deductibles, or uncovered
procedures. If you have a hearing aid benefit, you may be required to pay for your hearing aid upfront.
Upon receipt of payment from your insurance company, we will reimburse you for the amount that the
insurance company covered/paid. PLEASE INITIAL: __________
PLEASE BRING YOUR INSURANCE CARD(S) WITH YOU TO BE COPIED FOR YOUR FILE.
If health insurance is not in your name, please provide the following information:
___________________________________ _______________________________
Name of insured Relationship to patient
___________________________________ _______________________________
Insured’s Date of Birth Insured’s Employer
I hereby authorize Brown Hearing Centers to furnish information to my insurance carrier concerning
my illness and treatment, and I hereby assign to Brown Hearing Centers all payments for services
rendered to my dependents or myself. I understand that I am responsible for payment of all charges
not covered by my insurance provider.
SIGNATURE______________________________________________ DATE________________
PLEASE READ AND SIGN/INITIAL:

In order to keep your medical file up to date, we will be happy to provide your physician with a copy of our
audiological findings. Please initial ONE  Send a copy to my physician ______ (initial)
DO NOT send a copy to my physician ______ (initial)
Privacy Practice Notice: According to government law, we are required to make available to you a
copy of our privacy practice notice. Your signature below acknowledges your receipt of such:
SIGNATURE______________________________________________ DATE_______________________
MEDICAL:
Do you have pain/discomfort in your ear? Right _____Left _____Both _____
Do you have you any drainage in your ear? Right _____Left _____Both _____
Do you have a history of ear infections? Right _____Left _____Both _____
Do have ringing or other noises in your ear? Right _____Left _____Both _____ Is it constant or intermittent?
Do you have dizziness or vertigo? Yes _____ No _____
Have you ever had ear surgery? Right _____Left _____Both _____
Please describe___________________________________________________________________
Have you seen your physician regarding any of the above?____________________________________
Please describe other medical conditions we should be aware of: _______________________________
PLEASE BRING A LIST OF YOUR MEDICATIONS TO YOUR APPOINTMENT.
HEARING:
Do you think you have a hearing loss? Yes_____No_____
Is there a family history of hearing loss? Yes_____No_____ If yes, who: _______________________
Have you had noise exposure? Yes_____No_____
If yes, from work/military/hobbies, etc., please specify _____________________________________
Have you had your hearing tested before? Yes_____No_____ When__________ Results___________
Do you currently use a hearing aid? Yes_____No_____
If yes, How long? ______ What type?________________ Are you satisfied with it? Yes____No____
Mark the areas you have difficulty hearing/understanding and rate the level of the problem as follows:
Never  ¼ of the time  ½ of the time  ¾ of the time  Always 
Communication difficulties when speaking with one person (i.e., spouse, store clerk) _____
Communication difficulties when speaking with small group (i.e., small dinner party, playing cards) _____
Communication difficulties when in a large group (i.e., church, club, meetings, lectures) _____
Communication difficulties with various types of entertainment (ex., movies, TV, theatre) _____
Communication difficulties when in a noisy environment (i.e., riding in a car, restaurants, parties) _____
Communication difficulties using communication devices (i.e., telephone, doorbell, PA systems) _____
Do you feel your hearing limits your personal or social life? Yes____ No____ If yes, please rate _____
Do problems or difficulty with your hearing upset you? Yes______ No_____
Do other people suggest you have a hearing problem? Yes_____ No_____
Do people leave you out of conversations or become annoyed because of your hearing? Yes____No___
Please tell us anything else you want to share about your hearing ______________________________
NOTES:
1/19/2022 9:16 PM

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Brown Hearing Centers: Personal Information

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Brown Hearing Centers

Where Technology Meets Tradition Since 1962

How did you hear about us?______________________________________________________

911 ADDRESS IF DIFFERENT___________________________________________________________________

TELEPHONE (HOME) _ (WORK)

BIRTHDATE________ AGE_ MALE FEMALE MARITAL STATUS _________

FULL NAME AND PHONE NUMBER OF PRIMARY CARE PHYSICIAN __________________________________

NAME & TELEPHONE OF NEAREST RELATIVE____________________________________________________

INSURANCE INFORMATION - PLEASE READ AND SIGN/INITIAL:

PLEASE READ AND SIGN/INITIAL:

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