Patient Intake Form | New Patient Forms | Chesapeake Bay E.N.T. - Otololaryngology / Head and Neck Surgery on the Eastern Shore of Virginia

Ear - Check all that apply

Tinnitus (Ringing)

Hearing Loss (please see below)

If you answered yes to any of the above, please answer these questions.

Y or N
	Do people complain that you turn the TV volume too high?
	Do you have trouble understanding conversation in background noise?
	Has a friend or family member mentioned that you could have a hearing problem?
	Do voices sound blurry - like people mumble?
	Do you need to turn toward the person speaking or cup your ear to understand what is being said?