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Hearing Healthcare, Inc. Today's Date:___/___/___PATIENT INFORMATION: (circle) Mr. / Mrs. / Ms. / Dr. Male / FemaleAdult / Childcare: First___Middle___Last___Street Address: ___ City:___State:___Zip
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How to fill out audiology case history form

01
Begin by providing your personal information such as name, date of birth, and contact information.
02
Fill out information about your medical history including any past or current medical conditions.
03
Provide details about your hearing symptoms such as any issues with hearing loss or tinnitus.
04
Include information about any previous hearing tests or evaluations you may have had.
05
List any medications you are currently taking.
06
Be sure to mention any family history of hearing loss or other relevant medical conditions.
07
Sign and date the form to confirm the accuracy of the information provided.

Who needs audiology case history form?

01
Individuals seeking evaluation and treatment for hearing-related issues
02
Patients visiting an audiologist for the first time
03
Medical professionals assessing a patient's hearing health
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The audiology case history form is a document that collects information about a patient's medical history, symptoms, and hearing-related issues.
Audiologists and other healthcare professionals who are evaluating or treating patients with hearing-related issues are required to file audiology case history forms.
To fill out an audiology case history form, healthcare professionals must gather information from the patient regarding their medical history, current symptoms, and any previous treatments or evaluations related to hearing.
The purpose of the audiology case history form is to gather comprehensive information about the patient's hearing-related issues to aid in diagnosis and treatment planning.
Information such as medical history, family history of hearing loss, current symptoms, previous treatments, and any exposure to loud noises or ototoxic medications must be reported on the audiology case history form.
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