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Case History – Intake Form

Please complete this form in advance of your booked appointment with us. It is important to complete all sections to the best of your ability in its entirety. If you have any questions please feel free to contact us:

  • HRM Locations: 902 482-2222
  • Bridgewater: 902 530-2222
  • New Minas: 902 681-2222
  • Kingston 902 681-2222
  • Yarmouth: 902 742-2222
  • Toll Free: 1 877 988-4327

Case History - Intake Form
First
Last
Can we forward a copy of your Hearing Health Report to your family doctor? *
How did you hear of us? *
Reason for visit; *
Previous Hearing Assessment: *
Have you ever been seen by an Ear, Nose and Throat Doctor - Otolaryngologist? *
Are you experiencing hearing loss in; *
Do you currently wear hearing aids? *
Are you experiencing any of the following; *
Do you have a history of noise exposure? *
Do you have a history of any of the following; *