Hearing Aid Evaluation Form

The Hearing Aid Evaluation Form is a comprehensive audiology intake form designed for audiologists, ENT specialists, hearing aid dispensers, and hearing clinics that evaluate patients for hearing loss and hearing aid candidacy. With approximately 15 percent of American adults reporting some degree of hearing difficulty, the demand for structured, efficient hearing loss assessment intake processes continues to grow. This form streamlines the pre-appointment data collection that audiologists need to conduct a focused, productive evaluation, reducing chair time spent on paperwork and allowing more time for diagnostic testing and patient counseling.

The form captures a detailed hearing history including the onset, duration, and progression of hearing loss, whether it affects one or both ears, associated symptoms such as tinnitus, dizziness, or ear pain, and any history of ear infections, surgeries, or trauma. An occupational and recreational noise exposure section identifies risk factors that may have contributed to hearing damage, while a communication difficulties assessment helps the audiologist understand the patient's real-world hearing challenges in settings like group conversations, telephone use, television listening, and noisy environments. For patients who already use hearing aids, the form documents their current devices, brand, model, years of use, and satisfaction level, which is critical for determining whether a new fitting, upgrade, or alternative technology is warranted.

Insurance information is collected through a structured verification section that captures the patient's plan details, hearing aid benefit coverage, and any prior authorization requirements, since hearing aid benefits vary significantly across insurers and many patients are unaware of their coverage. The integrated appointment booking feature allows patients to schedule their audiometric evaluation directly through the form, reducing the administrative back-and-forth that can delay care. Whether your practice focuses on diagnostic audiology, hearing aid fitting and dispensing, cochlear implant candidacy evaluation, or pediatric hearing assessment, this hearing loss assessment form ensures that every patient arrives with their history documented and their appointment confirmed.