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Salutation
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First name
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Last name
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Email
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Phone number
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Street address
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Unit/#/Suite
City
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State/Region
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Country/Region
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Postal code
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Date of birth
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Gender
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Marital status
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Employer
Job title
Primary Physician
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Primary Physician Phone Number
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Referring Provider
Please enter name, contact phone # of your referring provider.
How long have you had Hyperacusis?
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What treatments have you tried for Hyperacusis?
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Hearing Medical History (Check all that apply)
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Ear Surgery
Ear Infections
Chronic Earwax Buildup
Itchy Ears
Ear Pain
Meniere's Disease
Hearing Loss
Tinnitus
Perforated Ear Drum
Noise Exposure
Dizziness
Other
Please list medical problems, conditions, or surgeries we should be aware of.
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Please list all current medications and dosage.
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Audiogram
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Loudness Discomfort Level (LDL)
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CT of Temporal Bone (CT IAC)
Please read and review on consultation page.
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Acknowledgement
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Signature
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Date
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Month
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Day
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Year
Message
Any additional notes, or comments we should know.
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