Tinnitus Intake Form

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You are scheduled for audiometric tinnitus testing.

Remember to bring your insurance cards and a referral to the appointment if your insurance requires one.
You will be called 1-2 day before your appointment to remind you of your appointment
Contact Audiology for questions on intake form or appointment (814) 941-7770

Preparing for your procedure:

There is nothing you need to do to prepare for your appointment. This appointment will take from 60-90 minutes depending on severity of the symptoms and tests ran.

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

Office Visit 99203
Tinnitus Assessment 92625
Increment Sensitivity 92564
Audiometric Evaluation 92557
OAE diagnostic 92588
Acoustic Immittance 92570
Tympanogram & Reflex 92550
Loudness Balance 92562
Quicksin 92700
Cerumen removal 69202

Results and recommendations will be discussed at the appointment.

If you are unable to make your scheduled appointment, please give us at least a 24 hour notice. Due to the time set aside for your appointment, we find it necessary to charge $150 for patients who cancel with less than 24 hour notice or who fail to show up for this scheduled appointment.

Contact Audiology for questions or to cancel at (814) 941-7770

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

DOB

Emergency Contact

First

Last

Phone

Relationship

Primary Doctor

Location

Referring Doctor

Location

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

Are you on Hospice?

Name/Phone (if yes):

Primary Insurance Name

ID #

Group #

Primary Insurance Card Holder Name

Primary Card Holder DOB

Secondary Insurance Name

ID #

Group #

Do you have a history of?

Diabetes

Heart Trouble

High Blood Pressure

Meningitis

Stroke

Mumps

Family Loss of Hearing

Cancer

Do you smoke?

Circulation Problems

Scarlet Fever

Measles

Chronic Ear Infections

Ear Disease

Have you ever experienced dizziness, vertigo or loss of balance?

Ringing, buzzing or hissing of the ears?

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?

INSTRUCTIONS: The purpose of this questionnaire is to identify difficulties that you may be experiencing because of your tinnitus. Please answer every question.

Because of your tinnitus, is it difficult for you to concentrate?

Yes
Sometimes
No

Does the loudness of your tinnitus make it difficult for you to hear people?

Yes
Sometimes
No

Does your tinnitus make you angry?

Yes
Sometimes
No

Does your tinnitus make you feel confused?

Yes
Sometimes
No

Because of your tinnitus, do you feel desperate?

Yes
Sometimes
No

Do you complain a great deal about your tinnitus?

Yes
Sometimes
No

Because of your tinnitus, do you have trouble falling to sleep at night?

Yes
Sometimes
No

Do you feel as though you cannot escape your tinnitus?

Yes
Sometimes
No

Does your tinnitus interfere with your ability to enjoy your social activities (such as going out to dinner, to the movies)?

Yes
Sometimes
No

Because of your tinnitus, do you feel frustrated?

Yes
Sometimes
No

Does your tinnitus make it difficult for you to enjoy life?

Yes
Sometimes
No

Does your tinnitus interfere with your job or household responsibilities?

Yes
Sometimes
No

Because of your tinnitus, do you find that you are often irritable?

Yes
Sometimes
No

Because of your tinnitus, is it difficult for you to read?

Yes
Sometimes
No

Does your tinnitus make you upset?

Yes
Sometimes
No

Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?

Yes
Sometimes
No

Do you find it difficult to focus your attention away from your tinnitus and on other things?

Yes
Sometimes
No

Do you feel that you have no control over your tinnitus?

Yes
Sometimes
No

Because of your tinnitus, do you often feel tired?

Yes
Sometimes
No

Because of your tinnitus, do you feel depressed?

Yes
Sometimes
No

Does your tinnitus make you feel anxious?

Yes
Sometimes
No

Does your tinnitus get worse when you are under stress?

Yes
Sometimes
No

the Because social

Does your tinnitus make you feel insecure?

Yes
Sometimes
No

Over the last two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too much

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself—or that you are a failure or have let yourself or your family down

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things such as reading the newspaper or watching television

Not at all
Several days
More than half the days
Nearly every day

Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

Not at all
Several days
More than half the days
Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way

Not at all
Several days
More than half the days
Nearly every day

If you clicked on any problems above, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

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 the Lemme Audiology 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 $150 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

Click Here to read our full Notice of Privacy Practices

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