Occupational Medicine

Have you ever served in military?

Yes No

Have you ever been to a doctor for an ear-related problem?

No Right Left Both

Have you ever had a severe head injury?

Yes No

Have you ever had ear surgery?

No Right Left Both

Have you ever had an ear injury?

No Right Left Both

Have you ever had the measles?

Yes No

Have you ever had the mumps?

Yes No

Have you ever had kidney disease?

Yes No

Have you ever had scarlet fever?

Yes No

Have you ever had meningitis?

Yes No

Do you have diabetes?

Yes No

Patient Forms