Name:  Phone Number:

  Street Address:

  City:   State:   Zip:

  Date of Birth:   Physician:

  Referred By:

Please Check All That Apply:

  How Long Have You Had a Hearing Problem?   Years   Months

  Which Ear is the Problem Occuring?   Right    Left

    History of Middle Ear Problems

    Ear Surgery, If Checked Please Explain-

    Family History of Hearing Loss? Who?

    Diabetes

    Dizziness or Vertigo

    Ringing/Tinnitus   Right   Left   Occasionally   Constant

    Measles

    Mumps

    Rubella

    Heart Problems

    Cancer

    Currently Wearing Hearing Aid(s)   Right   Left