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.
LIST OF MEDICATIONS
LIST OF MEDICATIONS
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