Non-Music Industry Form

Confidential case history

Please complete this form to the best of your ability. Leave blank any questions that do not apply to you.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please check any of the following that you experience:

Other
If you selected "other" above, please explain:
If you selected "tinnitus" above, please describe:
Do you wear any of the following for casual listening throughout the day?

Please check any non-music sound exposure you have experienced:

Do you smoke tobacco?
If yes, how much and for how long?
Do you take aspirin?
If yes, how much and for how long?
Do you have caffeine intake?
If yes, how much and for how long?
Do you drink alcohol?
If yes, how much and for how long?
Please check any of the following that apply to your personal medical history:
If you selected "other," please explain:
Please mention anything else that you would like:
I hereby authorize Dr. Heather Malyuk to release any medical or incidental information that may be necessary for either medical care with other providers with whom I have signed a release form. (NOT REQUIRED)
Should be Empty:

Confidential case history