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    Personal Information:








    Left=RightLeft worse than RightRight worse than LeftCentral





    TelevisionRadioPhone BookInternet (Search Engine)Internet (Social Media)MailerFamily/FriendPhysicianOther


    Tinnitus History:








    NoneHearing AidMaskerTRTCounsellingMusic TherapyOther


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo



    General Hearing Problems:


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    Hearing LossTinnitusSensitivity to Loud Sounds

    Effect of the Tinnitus:








    General Health:



    Compensation:


    Medical Contact Details:




    YesNo

    Please arrive 15 minutes prior to your scheduled appointment time.