CEDRA Form

1

Name* This field is required.

First Name

Last Name

2

When talking on a telephone, do you understand what people say better in one ear than the other?* This field is required.

YESNO

3

Did the hearing loss in either of your ears develop suddenly?* This field is required.

YESNO

4

Have you ever had a sudden permanent change in your hearing?* This field is required.

YESNO

5

Do you have hearing loss in only one ear?* This field is required.

YESNO

6

Do you hear better in one ear than the other?* This field is required.

YESNO

7

Does your hearing change from day to day?* This field is required.

YESNO

8

As an adult, have you ever had more than one infection in the same ear during one year?* This field is required.

YESNO

9

Have you ever noticed pus, blood or other active fluid discharge from your ear?* This field is required.

YESNO

10

Have you ever been told by a physician that you have Meniere’s disease?* This field is required.

YESNO

11

Overall, how would you rate your health?* This field is required.

Very Good

Good

Poor

Very Poor

12

How often do you have dizziness?* This field is required.

Never

Occasionally

Frequently

Always

13

How would you rate your balance?* This field is required.

Very Good

Good

Poor

Very Poor

14

Do you have tinnitus, such as ringing, roaring, or cricket-like sounds in your ears?* This field is required.

YESNO

15

Do you have tinnitus in (check one)* This field is required.

Right Ear

Left Ear

Both Ears

Unsure

16

Do you have any of the following symptoms with your tinnitus?

17

Dizziness?* This field is required.

YESNO

18

Pressure in the ear?* This field is required.

YESNO

19

Fullness in the ear?* This field is required.

YESNO

20

Plugged feeling in the ear?* This field is required.

YESNO

21

Have you ever had any of the following symptoms lasting longer than 10 minutes?

22

Sudden drop in hearing in one or both ears * This field is required.

YESNO

23

A rapid change in vision in one or both eyes* This field is required.

YESNO

24

In the past 3 months, have you had any of the following symptoms?

25

Any persistent discharge from either ear?* This field is required.

YESNO

26

Pus or blood in your ears?* This field is required.

YESNO

27

A change in hearing in one or both ears?* This field is required.

YESNO

28

A head cold or sinus problem that made your hearing worse?* This field is required.

YESNO

29

Dizziness?* This field is required.

YESNO

30

Fell because of poor balance?* This field is required.

YESNO

31

A persistent or recurring headache?* This field is required.

YESNO

32

Recurring fever, night sweats, chills?* This field is required.

YESNO

33

On the next page if your score is 4 or higher, you should talk to your doctor about your symptoms.

34

Your score:If 4 or higher, you should talk to your doctor about your symptoms prior to visiting us.