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info@salushearing.com
289-963-1512

2200 Rutherford Road, Suite 202 | Vaughan Ontario

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Patient Intake Form

Please complete the Patient Intake Form below.
When completed click on the “SUBMIT” button at the bottom of the form.

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Date

MM slash DD slash YYYY

Reason for Appointment:

How did you hear about us?

Doctor

First Name

Last Name

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Parent or Guardian Name (if applicable):

Hearing and Medical History

Please check the conditions that you have experienced below

Near/far sighted or glaucoma

Ear Surgery

Ear Infections

Chronic Earwax Buildup

Developmental Delay

Itchy ears

Ear Pain

Dizziness

Sensitive to sounds

Blood Pressure

Cancer

Diabetes

Heart issue

Speech or Language Delay

Other

Medication List

Other:

Did your child pass his/her newborn infant hearing screening? (if applicable)

Yes

No

Unsure

Which ear do you hear better from:

Left Ear

Right Ear

Same in both ears

Consent for Services

I consent to the release of my hearing test report to my doctor listed above.

I agree to receive email correspondence for appointment reminders and other office news communications.

Do you experience noises in your ears or head (tinnitus)? If so, where:

Have you ever worked or played around loud noise? If so, please explain:

How ready are you to do something today to:
Indicate the number below from 1 [Not Ready] to 10 [I Am Ready]

Hear better

1

2

3

4

5

6

7

8

9

10

Not Applicable

Manage tinnitus

1

2

3

4

5

6

7

8

9

10

Not Applicable

Please check the top THREE listening situations where you would like to hear better.

Television

Telephone

Spouse

Meetings

In background noise

Driving

Music

Outdoor

Religious

Other

Other

Does your hearing problem…

Cause you to turn up the TV or radio to hear it?

Frequently

Sometimes

Rarely

N/A

Make it difficult for you to converse on the phone?

Frequently

Sometimes

Rarely

N/A

Cause you to have difficulty following conversations at a restaurant?

Frequently

Sometimes

Rarely

N/A

Limit your social or personal life?

Frequently

Sometimes

Rarely

N/A

Cause you to have to ask people to repeat themselves?

Frequently

Sometimes

Rarely

N/A

Cause you to have difficulty hearing when in the presence of background noise?

Frequently

Sometimes

Rarely

N/A

Cause you to have difficulty hearing women’s or children’s voices?

Frequently

Sometimes

Rarely

N/A

Cause you to hear people speak but fail to understand what they are saying?

Frequently

Sometimes

Rarely

N/A

Cause you to feel as though others mumble?

Frequently

Sometimes

Rarely

N/A

Cause you to feel stressed or tired when listening for long periods of time?

Frequently

Sometimes

Rarely

N/A

Current or Previous Hearing Aids

Right Ear

Manufacturer, Model & Style

Serial Number

Date

MM slash DD slash YYYY

Left Ear

Manufacturer, Model & Style

Serial Number

Date

MM slash DD slash YYYY

Do you use a cellular phone?

Yes

No

N/A

Which cell phone do you use?

iPhone

Android

Other

Cell Phone Model

We transform lives by helping people with hearing loss and tinnitus

protect their brain health and stay connected to what matters most.
Proudly Canadian and Independently Owned and Operated

Ready to take the next step towards better hearing?
Contact us to book an appointment.

Call us today:

(289) 963-1512

Map of Salus Hearing and Tinnitus Centre

2200 Rutherford Rd #202, Concord, ON L4K 5V2

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