Hearing loss intake that captures onset timing and symptoms up front
Patients tell you upfront which ear is affected, how long the hearing loss has lasted, and whether pain, drainage, or dizziness is involved, plus whether they can attend an in-person exam. Prior audiogram or hearing test details are captured before the lead reaches your CRM.
The exact intake your hearing loss leads complete
This is the real 6-question guided intake for Hearing Loss — the same flow your customers finish before you ever pick up the phone.
What a qualified hearing loss lead should tell you
Intake for patients reporting reduced hearing ability, capturing who is affected, which ear or ears, how long the change has lasted, whether pain, drainage, or dizziness is present, and any prior hearing testing before an in-person exam is booked.
- Experiencing Hearing Loss
- In Which Ear Or
- Long Has Hearing Loss
- Hearing Loss Accompanied By
- Hearing Test Or Evaluation
- Person Able Attend In-Person
The questions your team needs answered
Every hearing loss intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Who is experiencing the hearing loss? | Distinguishes a self-reported adult case from a caregiver reporting on a child or another adult, which changes what history staff need to collect before the visit. |
| In which ear or ears is the hearing loss occurring? | Segments the lead so you can route, price, and prioritize it correctly. |
| How long has the hearing loss been present? | Sudden onset carries the highest weight in the catalog because rapid hearing loss can require faster evaluation than gradual, long-standing decline. |
| Is the hearing loss accompanied by ear pain, drainage, or dizziness? | A yes on ear pain, drainage, or dizziness weights higher than a no, since these symptoms alongside hearing loss often point to a condition needing prompter attention. |
| Has a hearing test or evaluation been done previously? | Knowing whether testing was done recently, long ago, or never helps staff decide whether baseline audiometry needs to be scheduled alongside the exam. |
| Is the person able to attend an in-person ear exam appointment? | A no on in-person availability weights lower than a yes, surfacing patients who may need an alternative scheduling path instead of a standard exam slot. |
How Cliont scores hearing loss leads
Every answer is weighted automatically — no manual review required.
Value signals
- Sudden, within the last few days
- A few weeks
- Several months
- A year or longer
- Hearing Loss Accompanied By: yes
- Person Able Attend In-Person: yes
See the lead your team receives
Hearing Loss Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for hearing loss workflows
| Cliont capability | Hearing Loss application |
|---|---|
| Weighted scoring engine | Combines the sudden-onset duration answer with the accompanying-symptoms answer so cases suggesting possible sudden sensorineural hearing loss surface above routine, longstanding hearing decline. |
| Conditional branching | Routes the intake differently based on whether the hearing loss is self-reported, a child, or another adult, without asking irrelevant questions of the wrong respondent. |
| Document upload capture | Collects an existing audiogram or hearing test report at intake so staff know before the appointment whether baseline testing already exists. |
| CRM routing with scoring band | Sends each hearing loss lead to your CRM tagged with its score and band, so front-desk staff can prioritize sudden-onset cases over routine follow-ups. |
| Availability qualifier | Flags patients who cannot attend an in-person exam so scheduling staff can offer an alternative path instead of booking a slot they won't use. |
Common hearing loss lead scenarios
Sudden hearing loss with dizziness
Onset within the last few days plus ear pain, drainage, or dizziness triggers the highest-weighted combination in the catalog, flagging a case that often needs same-week evaluation.
Gradual hearing loss, never tested
An adult reports hearing loss over several months to a year with no accompanying symptoms and no prior testing, a lower-urgency but still legitimate work-up candidate.
Parent reporting a child's hearing
The 'who is affected' answer switches to a caregiver reporting on a child, often paired with uncertainty about which ear and no prior test history.
Caregiver, patient can't attend
Someone is filling out the intake on behalf of another adult who cannot attend an in-person exam, a combination that scores lower and may need a different scheduling path.
Prior test, follow-up needed
A patient tested more than a year ago now reports new or worsening symptoms, distinct from a first-time evaluation because history already exists.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More ear nose and throat intake templates
Hearing Loss lead-intake FAQs
How does the intake flag sudden hearing loss as more urgent than gradual loss?
The onset-duration question weights 'sudden, within the last few days' highest, and that weight compounds with a yes on accompanying ear pain, drainage, or dizziness, so the two answers together push the lead toward the top of your queue.
Does the intake handle a parent reporting on a child differently from a self-reported case?
Yes, the first question captures whether the hearing loss is in the patient, a child, or another adult the person cares for, so you can see at a glance whether you're triaging a pediatric or caregiver-reported case before booking.
What happens when a patient has never had a hearing test?
The prior-evaluation question records whether testing was done in the past year, more than a year ago, or never, which helps you decide whether the appointment should include baseline audiometry.
Can the intake tell me if the loss is in one ear or both?
Yes, patients select left ear, right ear, both, or not sure, so your team can distinguish unilateral cases, which sometimes warrant closer attention, from bilateral or uncertain presentations.
How are patients who can't attend an in-person exam handled?
A no answer on the in-person availability question carries a lower weight than a yes, so those leads still come through but are visibly distinguished from patients ready to be scheduled.
Should I use this intake for a child's hearing loss or the Pediatric ENT Evaluation subservice?
This intake works when hearing loss is the primary concern regardless of age, since it asks directly whether the patient is a child; use Pediatric ENT Evaluation if the concern spans multiple symptoms beyond hearing.
Can I require a prior audiogram upload before confirming the appointment?
You can request an audiogram or hearing test report as part of the required uploads, so staff have existing results in hand before the exam is scheduled.
Turn hearing loss visitors into qualified patients
Give every hearing loss visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.