You are scheduled for audiometric and/or vestibular testing.

Remember to bring your insurance cards and a referral to the appointment if your insurance requires one.
24 hours before, quit taking all medications and supplements, with the exception of life supporting medications. (Please consult with your physician prior to appointment)
You will be called 1-2 day before your appointment to remind you.
Contact Audiology for questions on intake form or appointment (814) 941-7770

Preparing for your procedure:

Wash your face thoroughly. Lotions and make-up should not be used.
No eyelash extensions allowed.
Do not eat or drink 4 hours before your appointment.
Do not consume caffeine 12 hours before your appointment.
Do not consume alcoholic beverages 48 hours before your appointment.
It’s a good idea to wear loose, light, comfortable clothing for the test and flat shoes. Avoid dresses.
It is recommended you have someone drive you to and from this appointment. Testing might make you dizzy but this is normal and temporary.

Testing can include any/all of the tests below depending on symptoms and severity:

Office Visit 99204
cVemp 92517
Caloric Bithermal 92537
Sinusoidal Vertical Axis Rotational 92546
EcoG 92584
Basic Vestibular Eval 92540
Use of Vertical Electrodes 92547
OAE 92588
Tymp and Reflex 92550
Audiometric Evaluation 92557
Neurodiagnostic 92653

Not covered by insurance is vHit no billing code yet Cost is $35.00 paid at time of service

vHit is newer and performed to provide information about the integrity of the lateral semicircular canal and provides important information to supplement information obtained in other tests. It is highly recommended as part of the battery of tests performed.

Name

First

Last

Email

DOB

Home Phone

Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

First

Last

Phone

Relationship

Primary Doctor

Location

Do you live in a skilled Nursing or Assisted Living Facility, or Rehab Center?

Yes
No

Are you on Hospice?

Yes
No

Name/Phone (if yes):

Primary Insurance Name

ID #

Group #

Primary Insurance Card Holder Name

(if Neck Holder

Primary Card Holder DOB

Secondary Insurance Name

ID #

Group #

Do you have a history of?

Circulation Problems

Yes
No

Meningitis

Yes
No

Measles

Yes
No

Mumps

Yes
No

Ear Disease

Yes
No

Scarlet Fever

Yes
No

Ringing, buzzing or hissing of the ears?

Yes
No

If yes, how often?

Which ear?

Right
Left
Both

Recent Surgery?

If yes, please explain:

Any history of trauma to the head?

Any history of noise exposure?

List any allergies:

What do you hope to gain from your visit?

Past Medical History

Do you, or have you had any of the following?

Migraine

Yes
No

Stroke/TIA

Yes
No

If so, when?

Parkinson's Disease

Yes
No

Seizures/Epilepsy

Yes
No

Multiple Sclerosis

Yes
No

Alzheimer's

Yes
No

Other Neurologic?

Heart Attack

Yes
No

If so, when?

Pacemaker

Yes
No

Peripheral Arterial Disease

Yes
No

High Blood Pressure

Yes
No

Low Blood Pressure

Yes
No

Other Cardiovascular?

Breathing Difficulties

Yes
No

Emphysema/COPD

Yes
No

Asthma

Yes
No

Other Respiratory?

Artificial Joints

Yes
No

If so, when?

Arthritis

Yes
No

Back Problems

Yes
No

Back Surgery

Yes
No

If so, when?

Neck Problems

Yes
No

Osteoporosis/ Osteopenia

Yes
No

Other Orthopedic?

Cataracts

Yes
No

If removed, when?

Glaucoma

Yes
No

Macular Degeneration

Yes
No

Other Vision?

Cancer

Yes
No

Type:

Diabetes

Yes
No

Neuropathy

Yes
No

Depression

Yes
No

Anxiety

Yes
No

Thyroid

Yes
No

Gastrointestinal Problems

Yes
No

Rheumatoid Arthritis

Yes
No

Tobacco Use

Yes
No

If yes, how much?

Alcohol Use

Yes
No

If yes, how much?

Other Health Issues Not Listed:

Patient Questionnaire

Equilibrium disorders may appear with a variety of symptoms. Some individuals may experience dizziness or vertigo while others may have imbalance or unsteadiness. Please spend a few minutes answering the questions regarding your history and symptoms. Answer the questions to the best of your ability but please be assured that how you answer will not affect your evaluation.

How or when did your problem first occur?

How long did it last?

Do you experience any of the following sensations? Please read the entire list first. Then select YES or NO to describe your feelings most accurately.

Do you experience motion, air or sea sickness?

Yes
No

Did you have motion sickness as a child?

Yes
No

Do you have a family history of motion sickness?

Yes
No

Do you have migraine headaches?

Yes
No

Were you exposed to any solvents, chemicals, etc.?

Yes
No

Have you ever fallen?

Yes
No

If yes, how many times?

Where? (Inside the home, outside the home?)

Are you afraid of falling?

Yes
No

If you have dizziness, please select either YES or NO, and fill in the blank spaces. If you do not experience dizziness, please go to the next section.

My dizziness is constant? If you answered yes, please go to the next section.

Yes
No

If in attacks, how often?

Are you completely free of dizziness between attacks?

Yes
No

Do you have any warning that the attack is about to start?

Yes
No

Is the dizziness provoked by head/body movement?

Yes
No

If so, which direction?

Do you know of anything that will stop your dizziness or make it better?

Yes
No

What?

...make your dizziness worse?

Yes
No

What?

...precipitate an attack?

Yes
No

What?

Do you know any possible cause of your dizziness?

Yes
No

What?

Do you experience any of the following sensations? Please read the entire list first then please select either YES or NO to describe your feelings most accurately.

Light headedness?

Yes
No

Swimming sensation in the head?

Yes
No

Blacking out or loss of consciousness?

Yes
No

Objects spinning or turning around you?

Yes
No

Sensation that you are turning or spinning inside, with outside objects remaining stationary?

Yes
No

Tendency to fall?

Yes
No

To the right or left?

Forward or backward?

Loss of balance when walking?

Yes
No

Veering to the right or left?

Do you have trouble walking in the dark?

Yes
No

Do you have problems turning to one side or the other?

Yes
No

Nausea or vomiting?

Yes
No

Pressure in the head?

Yes
No

Do you have any of the following? Please select either YES or NO and select the ear involved.

Difficulty in hearing?

Yes
No

When did this start?

Is it getting worse?

Does the hearing change with your symptoms?

Yes
No

If so, how?

Noise in your ears?

Yes
No

Describe the noise:

Does the noise change with your symptoms? If so, how?

Does anything stop the noise or make it better?

Fullness or stuffiness in ears?

Yes
No

Which Ear?

Does this change when you are dizzy?

Pain in your ears?

Yes
No

Which Ear?

Discharge from your ears?

Yes
No

Which Ear?

Please list all of your current medications and supplements. We can copy at visit if you already have this on paper.

Prescription

Dosage

Frequency

Reason

Over the counter

Dosage

Frequency

Reason

Supplements & Vitamins

Dosage

Frequency

Reason

Consent for Treatment

The patient/legal guardian authorizes LAA Center for Balance staff to administer appropriate testing and/or treatment for the patient’s diagnosis/rehabilitation. The patient/legal guardian agrees that no guarantee or assurance has been made as to the results that may be obtained from the services rendered.

Consent to Release Medical Information

I authorize LAA to release any information acquired in connection with my diagnostic/treatment services including, but not limited to, diagnosis & clinical records, to myself, my insurance(s), physician(s), and

Authorized Name

Guarantee of Payment:

I agree to pay any charges that my insurance does not pay. I am responsible to pay any un-covered portion on the date services are rendered. I am responsible for any incurred costs on overdue balances including, but not limited to, late fees, interest fees, legal fees, and collection agency fees.

Cancellation/No Show Policy

I understand that my appointment is a reservation of time with a skilled health professional. Insufficient notice of missing an appointment detracts from my ability to get fully well and affects other patients as well. Appointments without sufficient notice (less than 48 hours) will be charged a $200 fee. My insurance does not cover these fees and it will be my responsibility to pay. If I repeatedly neglect my appointments, the office may dismiss me as a patient.

By signing below, I acknowledge that I had the opportunity to review the Notice of Privacy Practices, provided pursuant to the Health Insurance Portability and Accountability Act of 1996, located on LemmeAudiology.com.

Electronic signature

Date

Vestibular Intake Form

You are scheduled for audiometric and/or vestibular testing.

Do you have a history of?

Past Medical History

Do you, or have you had any of the following?

Patient Questionnaire

Consent for Treatment

Consent to Release Medical Information

Guarantee of Payment:

Cancellation/No Show Policy

Request an Appointment: