Otitis Media Form
Child's Full Name
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Preferred contact email address (*)
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When did your child’s ear problems begin?
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How many infections have occurred in the last 12 months?
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When did the last infection (if any) occur?
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Does your child suffer from ear pain
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How many days are they sore?
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Does your child wake at night from ear pain?
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How many doctors visits have been necessary
for the ears in the last 12 months?
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How many courses of antibiotics for the ears
have been necessary in the last 12 months?
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Have the ears discharged?
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Do your child’s ears ever “clear” (has your doctor noted
that they are not inflamed)?
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If grommets have been inserted before,
please state approximate dates or age.
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Do you think your child is hearing normally?
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Do you think your child has normal speech
and language development?
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Is there a family history of ear disease?
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Does your child attend pre-school/kindergarten/day care?
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Does your child snore?
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While sleeping do they stop breathing briefly at times?
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Does your child have problems with a persistently runny nose?
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Does your child have problems with their tonsils?
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Has your child had a hearing test?
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Have you read the otis media information on my website? (*)
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Any other comments?



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The captcha is case sensitive - on an ipad it will automatically capatilise the first letter - make sure you turn this off on the keyboard (*) The captcha is case sensitive - on an ipad it will automatically capatilise the first letter - make sure you turn this off on the keyboard
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