Patient Information Patient first name* Patient last name* Phone* Email Birth year* Year1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 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 CentralCalgary ChinookCalgary NorthCalgary SouthCalgary University DistrictCranbrook, BCCreston, BCFernie, BCGolden, BCInvermere, BC