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Audiology Hearing Screening Form

Asks about primary hearing concern, which ear is affected, and duration of symptoms. Built for audiology clinics.

Questions
10
Page
1
Time
about 3 min
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Your practice

Audiology Hearing Screening Form

Live preview. Tap through it like a patient.

Who it is for

  • Audiology Clinics
  • ENT Specialty Practices
  • Occupational Health Centers
  • Veteran Affairs Audiology
  • Retail Hearing Aid Centers

What's inside

Before you publish: Clinical review required: this worksheet does not calculate scores, diagnose, or recommend treatment. Confirm the questions and response options against your approved assessment protocol before use.

  1. Patient NameText · Required
  2. Date of BirthDate
  3. Primary Hearing ConcernLong Text
  4. Which Ear is Affected?Long Text
  5. Duration of SymptomsLong Text
  6. Tinnitus Present?Long Text
  7. Noise Exposure HistoryLong Text
  8. Dizziness or Balance Issues?Long Text
  9. Assessor NameText
  10. Clinical NotesLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Audiology Hearing Screening Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

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Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Audiology Hearing Screening Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Audiology Hearing Screening Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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