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Information we need from you, a copy of your audiogram and the questionnaire below

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1) Persistent pain affecting either ear (defined as earache lasting more than 7 days in the past     90 days before appointment)  Yes / No 2) History of discharge other than wax from either ear within the last 90 days Yes / No 3) Sudden loss or sudden deterioration of hearing (sudden=within 1 week, in which case  Yes / No 4) Rapid loss or rapid deterioration of hearing (rapid=90 days or less)  Yes / No 5) Fluctuating hearing loss, other than associated with colds  Yes / No 6) Unilateral or asymmetrical, or pulsatile or distressing tinnitus lasting more than 5 minutes at a          time Yes / No  7) Troublesome, tinnitus which may lead to sleep disturbance or be associated with symptoms of  anxiety or depression Yes / No 8) Abnormal auditory perceptions e.g distorted sounds, music in your head ,if yes give details Yes / No 9) Vertigo including dizziness, swaying or floating sensations Yes / No  10) Diabetic Yes / No 11) Family history of hearing problems Yes / No 12) Normal peripheral hearing but with abnormal difficulty hearing in noisy backgrounds; possibly having problems with sound localization, or difficulty following complex auditory directions. Yes / No 13) Any history of ear surgery, perforation, abscess  etc Yes / No , If yes then elaborate:
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