Intake Form

Birth Date (required) *

Gender (required) *
MaleFemaleSpecified

—Please choose an option— Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Coverage through any of the following?
Veterans AffairsIndigenous Services CanadaWorkSafeBCMinistry of Social Services

1. What do you do for work? RetiredOther

2. Do you have difficulty hearing someone speak in noisy environments? YesNo

3. Do you have difficulty hearing in group settings? YesNo

4. Do people often seem to mumble when speaking? YesNo

5. Are certain voices easier to hear than others? (e.g., hearing men better than women) YesNo

6. Do you frequently ask people to repeat themselves? YesNo

7. Do you have difficulty hearing on the phone? YesNo

8. Do you have trouble hearing the TV or tend to increase the volume? YesNo

9. Is your hearing better in one ear than the other? YesNo

10. Have you ever worn hearing aids or been advised to use them? YesNo

Please check any that apply to you:
DiabetesAllergiesShinglesHead TraumaStrokePacemakerHigh Blood PressureHeart Problems

• Ear infection within the last 90 days: YesNo

• Discharge or drainage from the ears in the last 90 days: YesNo

• Pressure or pain in your ears: YesNo

• Previously diagnosed ear disease: YesNo

• Vertigo, dizziness, or balance issues: YesNo

• History of ear surgery: YesNo

• Ringing in the ears (Tinnitus): YesNo

• Family history of hearing loss: YesNo

• Sudden hearing loss: YesNo

• Worked in noisy environments: YesNo

• Previous hearing test: YesNo