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  AAO-INS Medical Referral Criteria -1996

Subject Information

Date of Birth:  
Today’s Date:
AAO-INS Medical Referral Criteria -1996
Have you recently experienced pain in either ear? 
Have you recently experienced a draining ear?
Have you recently experienced dizziness?
Have you recently experienced severe tinnitus (ringing)?
Have you recently experienced sudden hearing loss? 
Have you recently experienced fluctuating hearing loss?
Have you recently experienced ear fullness or discomfort?
Have you recently had problems wearing hearing protection?
Medical History:
Have you ever served in the military?
Have you ever been to a doctor for an ear-related problem?
Have you ever had a severe head injury?
Have you ever had ear surgery?
Have you ever had an ear injury?
Have you ever had measles?
Have you ever had mumps?
Have you ever had kidney disease?
Have you ever had meningitis?
Do you have Diabetes?
Do you have high blood pressure?
Do you have an existing hearing problem?
Do you have frequent ear infections?
Do you shoot guns or hunt?
Do you wear a hearing aid?
Do you participate in loud activities (music, motorcycle)?
Do you currently use prescription or over the counter drugs?
Are you suffering from allergies?
Does any of your immediate family have hearing problems? 

Do you have any other comments on the health of your hearing?

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