Advanced Hearing Center
Will this be your first hearing test? Yes No. Have you ever had surgery? Yes No (If yes, what)_____ Do you have any of the following: ♦Deformity of the ear? Yes No ♦Sudden or rapid hearing loss in the past 90 days? Yes No ♦Acute or recurring dizziness? Yes No. Has your hearing in one ear worsened in the past 90 days? Yes No ................
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