Patient Intake Form

Patient Information

Last Name

First Name

Date of Birth

Sex

Pronouns

Address

City

State

Zip

Phone

Email

Preferred method of contact

Marital Status

Emergency Contact

Name

Relationship

Phones

Insurance Information

Primary Insurance Provider

Member ID / Policy Number

Group Number

Subscriber Name

Date of Birth

Relationship to Subscriber

Secondary Insurance Provider

Primary Care Provider & Referring Provider

Name of Primary Care Physician (PCP)

PCP Phone

PCP Fax

Referring Physician (if different)

Reason for Referral

Appointment & Medical History

Reason for Visit / Main Concern

When did symptoms begin? Estimated Date

Have you seen another provider for this issue?

Yes

No

Known Allergies (Medication, Food, Environment)

Medical History (check all that apply or write in)

Diabetes

Hypertension

Heart Disease

Asthma

Cancer (Type)

Stroke

Thyroid Disease

Other

Family History

Check any family history of the following:

Hearing Loss

Allergies

Cancer

Diabetes

Other relevant conditions

Relationship to Family Member(s) with History

Additional Specialty-Specific Questions

Have you ever had your hearing tested?

Yes

No

If yes, when

Do you have:

Hearing Loss

Ringing in Your Ears

Balance or Dizziness Issues

Do you use a hearing aid or cochlear implant?

Do you experience chronic sinus issues or allergies?

Do you snore or have been diagnosed with sleep apnea?

HIPAA Acknowledgment & Consent

Today's Date

About

Resources

Our Providers

Our Providers

Locations

Proudly Serving the Greater Camas area for 35 years!

Downtown Office

Uptown Office

Ear, Nose & Throat Care

Audiology & Hearing

Allergy & Sinus

Facial Plastics/Med Spa

Speech Therapy

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Manufacturers Menu

Balance Menu

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Facial Cosmetics Menu

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