Patient Registration Packet

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PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE


PARENT/GUARDIAN IF PATIENT IS UNDER 18 YEARS OF AGE

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PRESENTING PROBLEM


PRESENTING PROBLEM

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HISTORY


HISTORY

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Tinnitus Questions
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Noise Exposure Questions
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Family History
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MEDICAL HISTORY: Please check if you have experienced any of the following:


MEDICAL HISTORY: Please check if you have experienced any of the following:

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HEARING HANDICAP INVENTORY


HEARING HANDICAP INVENTORY

Instructions: Answer Yes, No, or Sometimes for each question. Do not skip a question if you avoid a situation because of a hearing problem. If you use a hearing aid, please answer according to the way you hear with the aid.
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LIST OF MEDICATIONS


LIST OF MEDICATIONS

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