ADULT HEARING ASSESSMENT

PRE-APPOINTMENT QUESTIONNAIRE

Background Details

First Name *

Last Name *

Date of Birth *

Gender *

MaleFemaleOther

Mobile Phone Number *

Email Address *

Address *

Street address

Suburb

State

Postcode

GP's Name

GP Practice Name

Medicare

Medicare Number (with reference number)

Medicare Expiry Date

Clinical Concerns

What is the main reason for your appointment at SASHC?

When did the problem first develop?

Has your hearing been tested before?

YesNoUnsure

If yes, when was your hearing last tested?

What was the outcome of your last hearing assessment? (bring report/letter if possible)

Is there a family history of hearing loss/ear related issues?

YesNoUnsure

If yes, who was impacted in your family?

Have you ever had surgery on or around your ear(s)?

YesNoUnsure

If yes, please state when and what the surgery was for.

Do you ever experience tinnitus/ringing in your ear(s)?

YesNoUnsure

If yes, which ear?

Right EarLeft EarBoth EarsUnsure

Do you ever experience vertigo/dizziness?

YesNoUnsure

If yes, how often and how long do these episodes last?

Do you experience a sense of fullness/blocked feeling in your ear(s)?

YesNoUnsure

If yes, which ear?

Right EarLeft EarBoth EarsUnsure

Do you have a history of noise exposure?

YesNoUnsure

If yes, when and why were you exposed to noise?

Referrer Details

Who referred you to SASHC?

If not referred, how did you hear about SASHC?

Doctor/SpecialistFriendGoogleOther

If other, please comment.

Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing services to you. This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of your assessment and treatment, is kept securely. In the interest of your/your privacy this information is only used by your therapist/s and authorised SASHC staff. Your personal information is retained for record keeping purposes and enables your therapist to provide a relevant and informed service to you. A more detailed description is provided in the SASHC “Privacy Policy”. This policy is available to you on request.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. SASHC will discuss with you your different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved in your care.

Please notify us if you do not wish us to disclose this information.

However, we are legally required to breach confidentiality without consent if:

You or someone else is at immediate risk of serious harm or death
A child is being abused, neglected, or at risk
An elderly or dependent person is being abused or neglected
It is required by court order or subpoena
During an AHPRA investigation of your care.

If you lack decision-making capacity, a guardian or substitute decision-maker must also consent. If you disclose immediate risk of harm to yourself or others, we are legally required to inform appropriate authorities, even without your consent. This is part of our duty of care.

We will not disclose your information to third parties (employers, insurers, family, other providers) without your prior written consent AND without clear specification of what information, to whom, for what purpose, and any limits on use you consent to.

Clinicians are required to consult and receive supervision from colleagues from time to time. If your information is shared in this context, all care is taken to deidentify your information in such a way that you remain anonymous.

GP Referrals

If you are attending under a GP referral and Chronic Disease Management Plan, progress letters to your GP at requested review points are mandatory. Please speak with our admin team or your practitioner if you have any concerns about what information about your treatment and personal circumstances is shared.

Audio/Video Recording

As a therapeutic clinic, we often make recordings of sessions and assessments for both analysis and planning. We may also utilise some of these recordings for teaching purposes. Your recordings will be kept secure and will not be shown to individuals not associated with our practice/clinic.

On behalf of SASHC, we undertake that, in respect of any audio/video recordings made, every effort will be made to ensure professional confidentiality and that any use of these audio/video recordings, or descriptions of audio/video recordings will be for professional use only and in the interest of improving professional standards through research and training programmes. Every effort will be made to ensure the anonymity of all those involved in the session.

Do you agree with the audio/visual statement above? *

YesNo

Fees and Cancellations

A clear business day means a full working day between the day you contact us and your appointment day. The day you notify us and the appointment day itself does not count. For example, for a Friday appointment, cancel by Tuesday to avoid a cancellation fee.

Self-funded appointments

A cancellation fee of $50 is payable upon any appointment canelled within 2 business days of the scheduled appointment. We will make every effort to send out reminders for upcoming appointments, however it is your responsibility to inform us if you cannot make these appointments.

No shows will be charged 100% of the appointment cost.

NDIS appointments

We understand that at times appointments will need to be cancelled due to illness and unavoidable circumstances. However, in order to provide an affordable and viable service, SASHC has adopted the following cancellation policy in line with NDIS policy.

We will send out reminders for all scheduled appointments, however, no shows and appointments cancelled within the short notice period (defined by the NDIS as less than 2 clear business days) from the scheduled time will incur a fee of 100% of the agreed fee associated with the activity from the Participant's plan. We will make every effort to send out remiders for upcoming appointments, however it is your responsibility to inform us if you cannot make these appointments.

Late attendance

We make every effort to send out appointment reminders, and we ask that you respect our clinicians time. Arriving late not only impacts your appointment but also those of other patients scheduled throughout the day. Consequently, we are unable to complete full assessments for late arrivals. Therefore, patients who arrive 10 minutes or more past their scheduled appointment time will not be seen and a full appointment fee will be charged.

Outstanding Accounts

Outstanding accounts of more than 30 days without any response to reasonable contact attempts may be referred to an external debt collection agency. To assist with debt recovery, only your contact details will be provided; information regarding your treatment and personal circumstances will remain confidential.

Where an invoice remains unpaid and is referred to a third-party debt collection agency, the client will be liable for any reasonable debt collection costs incurred by SASHC in recovering the outstanding amount.

Fees and Rebates

Fees Payable

If you are a Medicare client, you are required to pay the fee in full on the day of the appointment. Your rebate will be processed through MEDICARE and will be deposited into your nominated bank account within 24 hours of service if you are registered with MEDICARE for rebates.
All private health rebates will be made through HICAPS on the day of the appointment.
If you are an NDIS participant and the NDIA does not pay any account associated with the service provided you will be legally responsible to pay SASHC for the unpaid accounts.
Reports of any type will not be released without prior payment.

Consent

I (please print name) *

have read, understood and agree to the above conditions, and as the authorised person, agree to the provision of services by SASHC.

Signature *

Draw signature|Type signatureClear

Date *