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 /your child in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your/your child’s situation, such as your/your child’s 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/your child’s assessment and treatment, is kept securely. In the interest of your/your child’s privacy this information is only used by your/your child’s therapist/s and authorised SASHC staff . Your personal information is retained for record keeping purposes and enables your/your child’s therapist to provide a relevant and informed service to you/your child. 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/your child’s 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/your child’s care.

Please notify us if you do not wish us to disclose this information or if a child protection/court order is in place.

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

Cancellations

Self-funded appointments

A cancellation fee of $50 is payable upon any appointment cancelled within 48 working hours (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 fee.

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.

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.

Fees and Rebates

Fees Payable

If you are a Medicare client, you are required to pay the fee in full. Your rebate will be processed through HICAPS at the time of payment or it may be deposited into your nominated bank account within 24 hours of service.
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 *