Step 1 of 250%Patient InformationPreferred Title(Required)Mr.MasterMissMrsMsDr.OtherFull Name(Required)Please enter preferred titleStreet Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred Phone Number(Required)Email Date of Birth(Required) MM slash DD slash YYYY Heath Card Number and Version Code (If required by office, may need at appointment)Name that appears on Heath CardFamily Doctor's Name(Required)Family Doctor's office number(Required)Present/Past OccupationPrimary Contact for appointments (if other please fill out name, relationship and phone number) Patient OtherTo get a better understanding of who you communicate with on a daily basis, please let us know who resides in the same household with you: Spouse/Partner Children Parent Roommate Live Alone OtherCase History InformationDo you feel you have hearing loss(Required) Yes, in both ears Yes, only in my left Yes, only in my right NoHow long do you feel you've had hearing loss?(Required)1-2 months3-6 months6-12 months1-2 years3-5 years5-10 years10+ yearsHave you ever had a hearing test? If yes, when?Any Present Medications?Do you have or have you ever experienced any of the following?<br /> (Please check all that apply) Tinnitus (ringing in the ears) Ear infections Ear fullness Ear surgery Head injury or trauma Dizziness or vertigo Family history of hearing loss Diabetes Allergies/Sinus Use a pace maker Meningitis Radiation or chemotherapy Stroke OR mini stroke Heart attack Use of blood thinnersHave you been exposed to loud noise at work? If yes for how long?Have you seen an Ear, Nose and Throat Specialist? If yes, who?Prior use of Hearing Aids? Yes NoIf you've used hearing aids are you satisfied with them? Yes NoIf you could improve something about your current hearing aids, what would it be?Additional Information Thank you for choosing Newcastle Hearing Solutions and placing your trust in us. Our goal is to provide superior hearing health care services to patients like you. We value your opinion and would appreciate you taking a moment to answer the following questions.How did you hear about Newcastle Hearing Solutions Patient Referral Family/Friend Referral Physician Referral Workplace Referral Sign On Building Google Facebook Website Magazine Newspaper OtherConsent(Required) I have read and understand the Privacy Statement below.Privacy Statement We understand the importance of privacy to our patients, and are committed to safeguarding your privacy. The information requested on this form will only be used to send you information about our products and services, and will not be rented, sold, or exchanged with any third parties. Once entered into our database, access is strictly controlled and information is kept for the sole purpose of sending out mailings and creating statistical reports. If you would ever like to update your information, or if you ever change your mind and wish to stop receiving information about our products and services, please call us and your information will be updated or deleted from our records.CAPTCHA
