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1. During intake, information to be collected as applicable from the patient and/or the patient’s family member/legal representative will include but is not limited to:
   1. Demographic and contact information
   2. Legal and financial documents (e.g., consent to treat, insurance, HIPAA, release of medical information, medical referral and/or medical order when required)
   3. Chief complaint, history of present illness, and current symptoms including functional impact of hearing or balance deficit
   4. Information related to medical and surgical history (including comorbidities), current medications, allergies, medical/specialist team members, and cognitive and developmental concerns
   5. Social history to include martial status, sexual orientation and gender identity, employment history, recreational history of alcohol, drug, and tobacco use and environmental factors such as noise exposure history (military, occupational and recreational)
   6. Screening for the red flags of ear disease²
   7. Tinnitus and falls risk including nature, onset and impact on patient's quality of life sufficient to develop a care plan which may include referral to an appropriate healthcare professional
   8. Audiologic history (e.g., previous hearing examinations, hearing amplification devices) as available
2. The following should be considered:
   1. Questioning may be completed in written or oral format
   2. Information shall be provided to and collected from the patient and/or patient’s family member/legal representative using methods required for effective communication (e.g. written, oral, or signed language and appropriate level to ensure understanding) in accordance with clinic policies
   3. Specialized questionnaires may be completed if relevant to appointment type (see standards for specific areas of evaluation)
   4. Questions shall be tailored to patient characteristics (e.g., age, cognitive function, reason for visit)
3. Following collection of information, the audiologist shall determine plan for evaluation
4. Intake information collection will continue throughout course of the initial appointment and subsequent visits. this should be updated at least annually

¹Audiologists are encouraged to familiarize themselves with the measures outlined in MIPS available at https://www.audiologyquality.org/measures/

²Red flags of ear disease: https://www.entnet.org/resource/position-statement-red-flags-warning-of-ear-disease/