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
Date
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.
Please check any of the following that you experience:

Tinnitus (ringing/buzzing in your ear(s) lasting longer than 5 minutes at a time)DistortionSensitivity to soundPitch perception issuesDifficulty understanding speech in background noiseDifficulty understanding speech in quietOther
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?

EarbudsEarphonesHeadphones

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

Do you smoke tobacco?

YesNo
If yes, how much and for how long?
Do you take aspirin?

YesNo
If yes, how much and for how long?
Do you have caffeine intake?

YesNo
If yes, how much and for how long?
Do you drink alcohol?

YesNo
If yes, how much and for how long?
Please check any of the following that apply to your personal medical history:

Ear infectionEar surgeryUse of life-saving medicationsDizziness/vertigoHeart diseaseKidney diseaseSudden hearing lossFluctuating hearing lossFamily history of hearing lossOther
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