Home
Hearing Aids
Hearing Care Services
Request Appointment
About Us
Schedule
New Patient Form
Please complete this form before your first appointment.
Confidential Patient Info
Select the office where you have your appointment
*
Select
Shawnee Office: 22120 Midland Drive, Suite 3 · Shawnee, Kansas 66226
Prairie Village Office: 5000 W. 95th Street, Suite 150 · Prairie Village, Kansas 66207
Name
*
First Name
Last Name
Age
Date of Birth
MM/DD/YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
Marital Status
Select
S
M
W
D
Occupation - Current or Previous
Secondary Contact Info
(###)
###
####
Physician
Physician's Phone
(###)
###
####
How did you hear about HearCare Hearing?
Examples: Newspaper ad, postcard or mail advertisement, TV, radio ad, referred by a friend, online, etc.
Confidential Patient Case History
Will this be your first hearing exam?
Yes
No
When was your last hearing test?
Select
Within last six months
Within last year
Within last two years
More than two years
Have you had ear surgery?
Yes
No
If yes, what type of surgery?
Do you find yourself forgetting things or suffering from memory loss?
Yes
No
Do you have any other medical conditions?
Yes
No
If yes, please explain:
Do you take any blood pressure or heart medications?
Yes
No
Please list medications:
Do you have any known allergies?
Yes
No
If yes, please list:
Hearing History
Do you have trouble understanding conversation?
Yes
No
Do you have trouble hearing in a crowd?
Yes
No
Do you have trouble hearing the telephone?
Yes
No
Do others complain that you play the TV too loudly?
Yes
No
On a scale of 1-10, with 1 being no hearing loss and 10 being severe hearing loss, how would you rate you hearing loss?
If a hearing loss is discovered, are you ready for help?
Yes
No
Hearing Needs Assessment - Please rank the factors below by how important they are to you when considering a hearing aid. Rank the options 1-4, using each number once.
Sound and Quality
1
2
3
4
Durability & Reliability
1
2
3
4
Cost
1
2
3
4
Appearance
1
2
3
4
Hearing Aid Experience
I have a hearing aid and use it regularly
I have a hearing aid but I don't use it often
Yes
No
I have tried a hearing aid, but returned it
Yes
No
I have inquired about hearing aids, but have never purchased one
Yes
No
I have never used a hearing aid
Are you concerned that hearing difficulty is hampering your personal or social life?
Yes
No
Thank you!
