New Patient Forms

Complete these forms prior to your first visit.

Medical and Surgery History
Patient Health History Form
HIPAA Form
Patient Check-In Form
Financial Waiver
Authorization to Release Medical Information to Individuals

Follow-up Forms

Balance Testing Instructions
Dizziness History Questionnaire

Hearing Loss Survey

Take your hearing health seriously! Complete our quick 5 minute hearing survey to access your hearing health needs today!

Start Now

Click here to begin our Online Hearing Survey.

Hearing Survey

Please answer the question below to the best of your ability. After you choose your answer, the next question will appear. At the end of the survey, you will be provided with a score, and you may send this score to us so we may discuss any hearing loss issues you are having.

Are there situations in which you find it difficult to hear clearly?

Do you have to strain to understand conversations?

Do you have a problem hearing over the telephone?

Do you have trouble following a conversation when two or more people are talking at the same time?

Do you have trouble hearing conversations in a noisy background such as a restaurant or a group gathering?

Do you have dizziness, pain, or ringing in your ears?

Do family members or coworkers remark about you missing what has been said?

Do people complain that you turn the TV volume up too high?

Do you find it hard to hear someone when they talk in a soft voice or whisper?

Do you find understanding women and children particularly challenging?

Almost Always Half the Time Occasionally Never

You received a score of

You are not experiencing common signs of hearing loss. However, if you suspect you may have hearing loss or are experiencing other symptoms not listed here, please contact our office for a consultation.

It appears you may be experiencing signs of a hearing loss. A hearing test can help detect early signs. We recommend contacting our office to schedule a hearing test.

Your responses indicate that you are experiencing common signs of a hearing loss. We recommend that you contact us to set up an appointment for a hearing test.

You are experiencing many signs of a hearing loss. It is highly recommended that you contact our office today for an appointment to meet with a hearing professional.

Check this box to verify you're a human.

Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

Click here to begin our Online Sino-Nasal Outcome Test (SNOT-20).

Sino-Nasal Outcome Test (SNOT-20)

Consider how severe the problem is when you experience it and how frequently it happens. Please rate each item below on how “bad” it is by selecting the button that corresponds with how you feel.

Need to blow nose

Sneezing

Runny nose

Cough

Post-nasal discharge

Thick nasal discharge

Ear fullness

Dizziness

Ear pain

Facial pain / pressure

Difficulty falling asleep

Wake up at night

Lack of sleep

Wake up tired

Fatigue

Reduced productivity

Reduced concentration

Frustrated / restless / irritable

Sad

Embarrassed

Problem as bad as it can be Severe Problem Moderate Problem Mild or Slight Problem Very Mild Problem No Problem

You received a score of

No problem to mild problem: You are not experiencing common signs of sinus issues. However, if you are experiencing other symptoms not listed here, please contact our office for a consultation.

Moderate problem: An appointment with a specialist or your Primary Care Physician is recommended and/or prescription medicine can be taken to treat symptoms.

Moderate to severe: An appointment with a specialist or your Primary Care Physician is recommended and/or prescription medicine can be taken to treat symptoms.

Severe to "as bad as it can be": An appointment with a specialist is recommended, treatment to be determined by the doctor.

Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

Click here to begin our Online Hearing Survey.

Hearing Survey

Are there situations in which you find it difficult to hear clearly?

Do you have to strain to understand conversations?

Do you have a problem hearing over the telephone?

Do you have trouble following a conversation when two or more people are talking at the same time?

Do you have trouble hearing conversations in a noisy background such as a restaurant or a group gathering?

Do you have dizziness, pain, or ringing in your ears?

Do family members or coworkers remark about you missing what has been said?

Do people complain that you turn the TV volume up too high?

Do you find it hard to hear someone when they talk in a soft voice or whisper?

Do you find understanding women and children particularly challenging?

Almost Always Half the Time Occasionally Never

You received a score of

It appears you may be experiencing signs of a hearing loss. A hearing test can help detect early signs. We recommend contacting our office to schedule a hearing test.

Your responses indicate that you are experiencing common signs of a hearing loss. We recommend that you contact us to set up an appointment for a hearing test.

You are experiencing many signs of a hearing loss. It is highly recommended that you contact our office today for an appointment to meet with a hearing professional.

Check this box to verify you're a human.

Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

Click here to begin our Online Sino-Nasal Outcome Test (SNOT-20).

Sino-Nasal Outcome Test (SNOT-20)

Consider how severe the problem is when you experience it and how frequently it happens. Please rate each item below on how “bad” it is by selecting the button that corresponds with how you feel.

Need to blow nose

Sneezing

Runny nose

Cough

Post-nasal discharge

Thick nasal discharge

Ear fullness

Dizziness

Ear pain

Facial pain / pressure

Difficulty falling asleep

Wake up at night

Lack of sleep

Wake up tired

Fatigue

Reduced productivity

Reduced concentration

Frustrated / restless / irritable

Sad

Embarrassed

Problem as bad as it can be Severe Problem Moderate Problem Mild or Slight Problem Very Mild Problem No Problem

You received a score of

No problem to mild problem: You are not experiencing common signs of sinus issues. However, if you are experiencing other symptoms not listed here, please contact our office for a consultation.

Moderate problem: An appointment with a specialist or your Primary Care Physician is recommended and/or prescription medicine can be taken to treat symptoms.

Moderate to severe: An appointment with a specialist or your Primary Care Physician is recommended and/or prescription medicine can be taken to treat symptoms.

Severe to "as bad as it can be": An appointment with a specialist is recommended, treatment to be determined by the doctor.

Thank you, your results have been successfully sent. Someone from our office will be in touch with you shortly.

(936) 582-7000

Please note that (936) 582-7000 is the only valid phone number for the clinic at this time.

Start Your Path To Better Health.

New Patient Forms

Follow-up Forms