PATIENT'S NAME ______________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

Your child had surgery performed in the past year. For the benefit of all our patients and physicians, we are trying to determine how successful our recommended surgeries are in eliminating the patient's problems. We ask you to take a minute and answer the following 7 questions.

1. How many ear infections (fever, ear pain, poor sleep, etc.) has your child had in the last 12 months?
0	1 or 2	3 to 5	more than 5
2. How many times has your child seen the doctor or gotten medicines for ear infections or ear fluid in the last year?
0	1 or 2	3 to 5	more than 5
3. Does your child currently have decreased hearing level either by hearing test or if not available, by your best assessment?
Yes	No
4. Did your child have continuing ear drainage for more than the first 2 weeks following surgery?
Yes	No
5. Overall compared to before the surgery, are your child's symptoms:
Resolved	Better	About the Same	Worse
6. Did the surgery meet your goals and expectations?
Yes	No
7. Would you still allow your child to have the surgery if you had the whole thing to do over again?
Yes	No

* Please print this form, complete it and bring or mail it to our office. Our mailing address can be obtained from our Office Information page.