Beltone Patient Medical Questions

Are you a new patient? We strongly encourage you to save time by completing this online medical questionnaire. You may also wait to complete this questionnaire until you arrive for your first appointment, or call us at 1800-497-7772 to answer these questions by phone.

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  6. Please answer the following questions from the perspective of the person named above.
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  8. Do you give us permission to send a copy of your hearing test results to your doctor?
  10. Are you currently suffering from a cold, flu or sinus illness?
  12. Have you ever experienced a heart attack or stroke (including T.I.A./mini stroke(s)?)
  15. Do you have any history of ear infection(s)?
  17. Have you ever had any type of ear surgery?
  20. Are you allergic to Penicillin?
  22. Do you regularly experience Tinnitus (ringing, buzzing and/or humming in your ear(s)?)
  24. Are both your ears the same strength or is one ear stronger?
  26. Does background or crowd noise interfere with your ability to follow a conversation?
  28. Do you take any medications regularly?
  31. Do you have a family history of hearing loss?
  33. Do you have any history of exposure to loud noise?
  35. Have you ever been diagnosed with, or treated for, Menier's Disease?
  37. Have you ever seen an E.N.T. (Ear, Nose and Throat Specialist)?
  41. Have you ever worn a hearing aid?
  43. In the last 90 days, have you experienced: visible, congenital or traumatic deformity of either ear?
  45. In the last 90 days, have you experienced: active drainage from either ear (not including wax)?
  47. In the last 90 days, have you experienced: sudden or rapidly progressing heairng loss?
  49. In the last 90 days, have you experienced: sudden or recent onset of unilateral hearingn loss?
  51. Pain in either ear?
  53. To the best of my knowledge, each question here has been answerd acurately.