Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Audiology Hearing Screening Form
Patient Name *
Date of Birth
____ / ____ / ________
Primary Hearing Concern
Which Ear is Affected?
Duration of Symptoms
Tinnitus Present?
Noise Exposure History
Dizziness or Balance Issues?
Assessor Name
Clinical Notes
Audiology Hearing Screening Form template from formisoft.com. formisoft.com/intake-templates/audiology-hearing-screening