Patient Information Patient first name* Patient last name* Phone* Email Birth year* Year19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Birth month* MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Birth day* Day12345678910111213141516171819202122232425262728293031 Patient Symptoms, History & Required Assessments Symptoms* Hearing Loss - Right EarHearing Loss - Left EarHearing Loss - Both EarsDizziness / Loss of BalanceTinnitusFacial numbnessMiddle Ear / Eustachian Tube DysfunctionOther History* Family History of Hearing LossOtotoxic Medication / Chemo / RadiationExcessive Noise ExposureSpeech & Language DelayChronic Ear InfectionsOther Required assessments* Full Clinical Audiological AssessmentHearing LevelsTympanometryHearing Aid EvaluationSpeech TestingTinnitus EvaluationConcussion AssessmentEvaluation of Current Hearing Aid(s)Custom Audio MonitorsCustom Ear Plugs for NoiseCustom Swim Plugs/ SleepOther Clinic & Physician Information Referring clinic* Referring physician* Physician Phone* physician Email* Preferred Assessment Location Location* Preferred LocationCalgary – ChinookCalgary – ShawnessyCalgary – University DistrictCalgary – CrowfootCalgary – North Hill MallCranbrook, BCCreston, BCFernie, BCGolden, BCInvermere, BC