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                 AAO-INS Medical Referral Criteria -1996

Subject Information Company:   SSN: Name: Date of Birth: DOB: MONTH January February March Aprill May June July August September October November December   DOB: DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DOB: YEAR 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Sex: SEX Male Female Today’s Date: TODAY'S DATE: Month January February March Aprill May June July August September October November December TODAY'S DATE: DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 TODAY'S DATE: Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 AAO-INS Medical Referral Criteria -1996 Have you recently experienced pain in either ear?  RIGHT LEFT BOTH NO RIght Left Both NO Have you recently experienced a draining ear? RIGHT LEFT BOTH NO RIght Left Both NO Have you recently experienced dizziness? YES or NO Yes No Have you recently experienced severe tinnitus (ringing)? RIGHT LEFT BOTH NO RIght Left Both NO Have you recently experienced sudden hearing loss?  RIGHT LEFT BOTH NO RIght Left Both NO Have you recently experienced fluctuating hearing loss? RIGHT LEFT BOTH NO RIght Left Both NO Have you recently experienced ear fullness or discomfort? RIGHT LEFT BOTH NO RIght Left Both NO Have you recently had problems wearing hearing protection? RIGHT LEFT BOTH NO RIght Left Both NO Medical History: Have you ever served in the military? YES or NO Yes No Have you ever been to a doctor for an ear-related problem? RIGHT LEFT BOTH NO RIght Left Both NO Have you ever had a severe head injury? YES or NO Yes No Have you ever had ear surgery? RIGHT LEFT BOTH NO RIght Left Both NO Have you ever had an ear injury? RIGHT LEFT BOTH NO RIght Left Both NO Have you ever had measles? YES or NO Yes No Have you ever had mumps? YES or NO Yes No Have you ever had kidney disease? YES or NO Yes No Have you ever had meningitis? YES or NO Yes No Do you have Diabetes? YES or NO Yes No Do you have high blood pressure? YES or NO Yes No Do you have an existing hearing problem? RIGHT LEFT BOTH NO RIght Left Both NO Do you have frequent ear infections? RIGHT LEFT BOTH NO RIght Left Both NO Do you shoot guns or hunt? YES or NO Yes No Do you wear a hearing aid? YES or NO Yes No Do you participate in loud activities (music, motorcycle)? YES or NO Yes No Do you currently use prescription or over the counter drugs? YES or NO Yes No Are you suffering from allergies? YES or NO Yes No Does any of your immediate family have hearing problems?  YES or NO Yes No Comments: Do you have any other comments on the health of your hearing? Use this space for comments or leave blank If you'd like to start over you can hit the "reset" button to clear the form.  PLEASE SIGN BELOW:   X                                                                                               Please diligently recheck your answers before signing. Thank you for your time! HorizonHealthAccess.com 2011 © Horizon Health Access P.C.