Patient Forms

Please click on the form, print, fill out, and bring to your appointment with you.

New Patient Intake Form
HIPAA Notice of Privacy Practices
Dizziness History Questionnaire
VNG Instructions

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Hearing Survey

Complete our hearing loss survey and take your hearing health into your own hands!

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Hearing Aid Guide

Download our guide and make informed decisions on the purchase of your next hearing device.

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Schedule With Us

Schedule an appointment today to speak with one of our licensed hearing professionals.

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Click here to begin our Online Hearing Survey.

Hearing Survey

Please answer the question below to the best of your ability. After you choose your answer, the next question will appear. At the end of the survey, you will be provided with a score, and you may send this score to us so we may discuss any hearing loss issues you are having.

Are there situations in which you find it difficult to hear clearly?

Do you have to strain to understand conversations?

Do you have a problem hearing over the telephone?

Do you have trouble following a conversation when two or more people are talking at the same time?

Do you have trouble hearing conversations in a noisy background such as a restaurant or a group gathering?

Do you have dizziness, pain, or ringing in your ears?

Do family members or coworkers remark about you missing what has been said?

Do people complain that you turn the TV volume up too high?

Do you find it hard to hear someone when they talk in a soft voice or whisper?

Do you find understanding women and children particularly challenging?

Almost Always Half the Time Occasionally Never

You received a score of

You are not experiencing common signs of hearing loss. However, if you suspect you may have hearing loss or are experiencing other symptoms not listed here, please contact our office for a consultation.

It appears you may be experiencing signs of a hearing loss. A hearing test can help detect early signs. We recommend contacting our office to schedule a hearing test.

Your responses indicate that you are experiencing common signs of a hearing loss. We recommend that you contact us to set up an appointment for a hearing test.

You are experiencing many signs of a hearing loss. It is highly recommended that you contact our office today for an appointment to meet with a hearing professional.

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Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

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Patient Forms