Patient Information Patient first name* Patient last name* Phone* Email Birth year* Year193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 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