Hearing History Form

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Alliance Health Resources Mobile Division Ltd. | 2910 Center St
Deer Park, TX | 77536 | 281.479.6672

The following form is for office personnel and account setup purposes. It is not intended to be a means to contact Alliance Health Resources for emergency medical needs. If your matter is urgent, please call 911.

Company*
SSN*
Employee ID
Name*
First Last
Email*

Your results may be sent to you by email. Please provide an email for which you can receive your results.
Birth Date*
Month
Day
Year
Gender*
Status
In Program
Hire Date*
Month
Day
Year
Language*
Comment
Have you recently experienced pain in either ear?*
Have you recently experienced a draining ear?*
Have you recently experienced a dizziness?*
Have you recently experienced severe tinnitus (ringing)?*
Have you recently experienced sudden hearing loss?*
Have you recently experienced fluctuating hearing loss?*
Have you recently experienced ear fullness or discomfort?*
Have you recently had problems wearing hearing protection?*
Have you ever served in the military?*
Have you ever been to a doctor for an ear-related problem?*
Have you ever had a severe head injury?*
Have you ever had ear surgery?*
Have you ever had an ear injury?*
Have you ever had measles?*
Have you ever had mumps?*
Have you ever had kidney disease?*
Have you ever had scarlet fever?*
Have you ever had meningitis?*
Do you have diabetes?*
Do you have high blood pressure?*
Do you have an existing hearing problem?*
Do you have frequent ear infections?*
Do you shoot guns or hunt?*
Do you wear a hearing aid?*
Do you participate in loud activities (music, motorcycle)?*
Do you currently use prescription or over the counter drugs?*
Are you currently suffering from allergies?*
Does any of your immediate family have hearing problems?*
Signature
Comments
This field is for validation purposes and should be left unchanged.

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Hearing
History Form