Hearing Test Intake Form

Hearing Test Intake Form — Form Fields

This healthcare template includes 7 fields. Collect patient information and hearing history prior to audiological evaluation. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Age (number, required)
• Primary Complaint (dropdown selection, required) — options: Difficulty hearing conversations, Ringing in the ears (tinnitus), Hearing loss in one ear, Muffled sounds, Routine check
• Have you had a hearing test before? (multiple choice, required) — options: Yes, No
• Do you experience any of the following? (select all that apply) (checkboxes, optional) — options: Ear pain or pressure, Dizziness or vertigo, Frequent ear infections, Exposure to loud noise
• Do you currently wear hearing aids? (multiple choice, required) — options: Yes, No
• Additional Comments or Concerns (long text, optional)