Healthcare Hearing Impairment Assessment Form

Healthcare Hearing Impairment Assessment Form

Patient Name:    Date of Birth:    Gender:

Patient ID / Chart #:

Patient Information

Insurance Information

Presenting Complaint

Date of Onset:    Duration:    Laterality:    Left    Right    Both

Tinnitus    Vertigo / Dizziness    Ear pain    Ear drainage
Aural fullness    Sudden hearing loss    Progressive decline    Fluctuating hearing

Medical and Otologic History

Diabetes    Hypertension    Autoimmune disorder    Neurological condition
Other:

Hearing Assessment History

Date of Last Audiogram:    Location / Provider:

Current user    Previous user    Never used

Examination and Test Plan

Tests Ordered (check all that apply):
Pure tone audiometry (air)    Pure tone audiometry (bone)    Speech audiometry
Tympanometry    Otoacoustic emissions (OAEs)    Auditory brainstem response (ABR)

Recommendations and Plan

Informed Consent for Audiological Assessment

I hereby authorize and consent to the performance of diagnostic hearing tests and procedures as indicated above, including but not limited to pure tone audiometry (air and bone), speech audiometry, tympanometry, otoacoustic emissions, and any other non-invasive audiological assessments deemed necessary by the clinician. I understand that these procedures are intended to evaluate hearing sensitivity and middle-ear function. The known risks are minimal and may include temporary discomfort from earphones or probe placement, transient dizziness, or amplification-related discomfort. There is no guarantee of improvement from testing. I have the right to ask questions, refuse any portion of the assessment, and withdraw consent at any time prior to or during testing without penalty to future care.

By checking the box below and signing this form, I certify that I have read and understand the above, that the information I have provided is accurate to the best of my knowledge, and that I consent to the audiological evaluation and associated record-keeping.

I consent to the audiological assessment and related procedures.

HIPAA and Privacy Acknowledgment

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information. I understand that my health information related to this assessment will be maintained in my medical record and may be used for treatment, payment, and healthcare operations in accordance with applicable law. I understand that I may request restrictions on certain uses or disclosures, and that written requests should be provided to the practice.

I acknowledge receipt of the privacy practices and understand how my information will be used.

Authorization to Release Results (Optional)

Expiration Date of Authorization:    I authorize release of my assessment results to the above recipient for the stated purpose.

Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of medical history may affect the interpretation of audiological results and subsequent care. I hereby authorize the clinician to perform the indicated tests and to document findings in my medical record.

Sign Now