About this template
An Audiology Patient Intake Form is essential for hearing care clinics, otolaryngologists, and audiologists to gather comprehensive background information before a patient's initial appointment. This digital form collects crucial details including demographic data, primary hearing concerns, previous hearing test history, prior hearing aid usage, medical and ear history, noise exposure background, and emergency contact details.
Streamlining the patient intake process eliminates clipboards and manual data entry errors, allowing clinicians to review medical histories and hearing symptoms in advance of the consultation. By deploying this template as a Google Form, clinics can provide a smooth, professional onboarding experience that respects patient time and ensures all necessary medical background and consent details are captured securely.
Key features
- Capture patient contact info and demographics in one organized place.
- Collect detailed history regarding hearing loss, tinnitus, and prior testing.
- Document past ear surgeries, medical conditions, and noise exposure.
- Gather emergency contact and primary care physician details effortlessly.
- Include medical disclosures and digital signature authorization fields.
Use cases
- New patient onboarding at private audiology and ENT practices.
- Pre-appointment health screening for specialized hearing evaluations.
- Collecting patient history for hearing aid fitting consultations.
What this form collects
- Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Please enter your date of birth.
- Gender (Multiple choice)Select your gender identity.
- Residential Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Email Address (Short answer)We will use this to send appointment confirmations and care instructions.
- Cell Phone Number (Short answer)Primary phone number for SMS or voice reminders.
- Home Phone Number (Short answer)Optional secondary contact number.
- Emergency Contact Name & Relationship (Short answer)Provide the name and relation of someone we can contact in case of an emergency.
- Emergency Contact Phone Number (Short answer)Phone number for your designated emergency contact.
- Primary Care Physician Name (Short answer)Name of your family doctor or primary physician.
- Primary Care Physician Phone & Fax (Short answer)Contact numbers so we can share consultation notes with your doctor if needed.
- Referral Source (Dropdown)How did you hear about our audiology clinic?
- Reason for Today's Visit (Paragraph)Describe your primary hearing concerns or symptoms (e.g., ringing in ears, trouble hearing in noise).
- Prior Hearing Test History (Multiple choice)Have you ever had a professional hearing test before?
- Prior Hearing Aid Use (Multiple choice)Do you currently wear or have you previously worn hearing aids?
- Medical Conditions & Ear History (Paragraph)List any relevant medical conditions, ear surgeries, chronic infections, dizziness, or history of trauma.
- Noise Exposure History (Checkboxes)Select any environments where you have experienced significant noise exposure.
- Blood Thinner Medication Use (Multiple choice)Are you currently taking any blood thinners or anticoagulant medications?
- Patient Acknowledgment and Electronic Signature (Short answer)By typing your full name below, you confirm that the information provided is accurate and consent to audiological evaluation.
- Signature Date (Date)Enter today's date.
FAQ
How can I share this audiology intake form with my patients?
You can easily share the form via email link before their appointment, embed it on your clinic's website, or have them fill it out on a tablet in your waiting room.
Can I customize the questions on this Google Form template?
Yes, once you convert or open the template in Google Forms, you have full control to add, edit, or remove questions to match your clinic's specific diagnostic requirements.
Where is the submitted patient data stored?
All responses are securely saved directly to a linked Google Sheet associated with your Google account, making it easy to review or export patient data.
Does this form support digital signatures?
You can include a text field for patients to type their legal name as an electronic acknowledgment, alongside a date field for consent records.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.