PATIENT'S NAME ______________________________________

PATIENT'S SIGNATURE _________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

Your child is to have surgery in the near future. 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 3 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

* 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.