New Patient Form

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Do you have a history of high blood pressure?
Do you have a history of cancer?
Do you have a history of diabetes?
Do you have a history of chronic ear infections?
Do you have a history of family loss of hearing?
Do you have a history of allergies?
Do you have a history of measles?
Do you have a history of scarlet fever?
Do you have a history of meningitis?
Do you have a history of stroke?
Do you have a history of mumps?
Do you have a history of cardiovascular disease?
Do you have a history of depression?
Do you have a history of anxiety?
Do you have a history of chronic arthritis?
Do you currently smoke?
Any history of ear disease?
History of exposure to noise?
Have you ever worn a hearing aid?
Have you noticed a decrease in speech clarity and/or understanding?
Any history of trauma to the head?
How did you hear about us? Select all that apply:

Hearing Difficulty Questionnaire

How would you rate your hearing quality in the following listening situations? With 1 being Very Poor and 5 being Very Good
Selected Value: 0
Selected Value: 0
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HIPAA - Health Insurance Portability and Accountability Act

I Grant a LAA Associate to release my protected medical information to the following person/people:

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.

 

Click Here to read our full Notice of Privacy Practices

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